• Arrhythmias

• Cardiology & Cardiovascular Medicine

One quality-of-care measure for patients with atrial fibrillation (AF) is adequate treatment with anticoagulant therapy. Jeffrey D. Simmons, MD, MPH, Florida International University Herbert Wertheim School of Medicine, Miami, Florida, USA, observed that many patients with AF at the Miami Beach Community Health Center (MBCHC) were not receiving anticoagulant therapy. A study in Australia in 2002 [Peterson GM et al. Int Med J 2002] showed that utilization of anticoagulant therapy is potentially limited by incorrect estimations of efficacy and safety with vitamin K anticoagulants. In that study, one third of cardiologists overestimated the benefit of anticoagulation.

Barriers to anticoagulation therapy at MBCHC include poor routine follow-up with visits often only for crisis management, inadequate or no health insurance, difficulty paying for out-of-pocket expenses for tests and medications, transportation issues, language/cultural barriers, and a high rate of concomitant mental health illness. For his study, Dr. Simmons searched the clinic electronic health records for patients with a diagnosis of AF but no prescriptions for a vitamin K antagonist, a factor Xa inhibitor, or a direct thrombin inhibitor. The electronic health records of 50 patients identified were reviewed to determine the risks for embolism and bleeding using the CHADS₂, CHA₂DS₂-VASc, and HAS-BLED scores. To ascertain provider treatment patterns, 12 providers who prescribe anticoagulants at the clinic were asked to rank factors used to determine whether anticoagulants would be prescribed, including risk of stroke or embolism, risk of bleeding, and patient adherence to treatment or monitoring.

The results demonstrated that the risk of ischemic stroke was higher than the risk of bleeding in these 50 patients. This suggested that other factors may have contributed to not prescribing anticoagulation therapy for these patients. Review of the medical records also revealed that the older CHADS₂ score was used more frequently than the newer CHA₂DS₂-VASc score. Physicians were asked to rank four determinants of deciding to prescribe anticoagulant therapy in order. The results were (highest to lowest): 1) risk of stroke; 2) patient adherence to treatment; 3) risk of bleeding; and 4) patient adherence to monitoring. This study confirmed that the prescription of anticoagulant therapy is not made solely based on a determination of stroke and bleeding risks.

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