PATIENT VALUES AND PREFERENCES FOR ANTITHROMBOTIC THERAPY FOR STROKE PREVENTION IN ATRIAL FIBRILLATION: A SYSTEMATIC REVIEW

SummaryGuidelines recommend that patients’ values and preferences should be considered when selecting stroke prevention therapy for atrial fibrillation (SPAF). However, doing so is difficult, and tools to assist clinicians are sparse. We performed a narrative systematic review to provide clinicians with insights into the values and preferences of AF patients for SPAF antithrombotic therapy. Narrative systematic review of published literature from database inception. Research questions: 1) What are patients’ AF and SPAF therapy values and preferences? 2) How are SPAF therapy values and preferences affected by patient factors? 3) How does conveying risk information affect SPAF therapy preferences? and 4) What is known about patient values and preferences regarding novel oral anticoagulants (NOACs) for SPAF? Twenty-five studies were included. Overall study quality was moderate. Severe stroke was associated with the greatest disutility among AF outcomes and most patients value the stroke prevention efficacy of therapy more than other attributes. Utilities, values, and preferences about other outcomes and attributes of therapy are heterogeneous and unpredictable. Patients’ therapy preferences usually align with their values when individualised risk information is presented, although divergence from this is common. Patients value the attributes of NOACs but frequently do not prefer NOACs over warfarin when all therapy-related attributes are considered. In conclusion, patients’ values and preferences for SPAF antithrombotic therapy are heterogeneous and there is no substitute for directly clarifying patients’ individual values and preferences. Research using choice modelling and tools to help clinicians and patients clarify their SPAF therapy values and preferences are needed.Supplementary Material to this article is available online at www.thrombosis-online.com.

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Faculty Opinions recommendation of Efficacy and Harms of Direct Oral Anticoagulants in the Elderly for Stroke Prevention in Atrial Fibrillation and Secondary Prevention of Venous Thromboembolism: Systematic Review and Meta-Analysis.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725514028.793512947 ◽

2016 ◽

Author(s):

Nanette Wenger

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Venous Thromboembolism ◽

Secondary Prevention ◽

Stroke Prevention ◽

Meta Analysis ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

The Elderly

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Abstract 14763: Patients With a Perceived High-bleeding Risk in a Randomized Controlled Trial of Alert-based Computerized Decision Support for Stroke Prevention in Atrial Fibrillation: An Af-Alert Substudy

Circulation ◽

10.1161/circ.142.suppl_3.14763 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Gregory Piazza ◽

Shelley Hurwitz ◽

Brett Carroll ◽

Samuel Z Goldhaber

Keyword(s):

Atrial Fibrillation ◽

High Risk ◽

Stroke Prevention ◽

Antithrombotic Therapy ◽

Controlled Trial ◽

Bleeding Risk ◽

Computerized Decision Support ◽

Risk Of Bleeding ◽

Randomized Controlled ◽

Risk For Bleeding

Introduction: A perceived increased risk of bleeding is one of the most frequent reasons for failure to prescribe anticoagulation for stroke prevention in atrial fibrillation (AF). We previously conducted a randomized controlled trial of alert-based computerized decision support (CDS) to increase prescription of antithrombotic therapy in 458 high-risk hospitalized patients with AF who were not being anticoagulated. Hypothesis: We hypothesized that patients with a perceived high risk for bleeding would have a similar HAS-BLED score and rate of major and clinically-relevant non-major bleeding. Methods: To determine the clinical characteristics and outcomes of these patients determined to be high-risk for bleeding, we analyzed the 248 patients in the alert group. Results: A perceived high risk of bleeding was the most common reason (77%) for omitting antithrombotic therapy. Median HAS-BLED scores were similar in these patients compared with those who were not deemed to have an increased bleeding risk (3 vs. 3, p=0.44). Despite being categorized as too high-risk for bleeding to receive antithrombotic therapy for stroke prevention at the time of the alert, nearly 12% of these patients were ultimately prescribed anticoagulation over the ensuing 90 days. The frequency of major and clinically-relevant non-major bleeding was similar between the two groups. Conclusions: In conclusion, a perceived high risk of bleeding was the most common reason for failure to prescribe antithrombotic therapy after the CDS alert. History of a prior bleeding event or underlying bleeding disorder was not reflected in a higher HAS-BLED score. Implementation of an alert-based CDS with specific attention to assessment of bleeding risk and mitigation warrants further study to encourage adherence to evidence-based clinical practice guideline recommendations for stroke prevention in AF.

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Doctors' beliefs on the use of antithrombotic therapy in atrial fibrillation: identifying barriers to stroke prevention

Internal Medicine Journal ◽

10.1046/j.1445-5994.2002.00156.x ◽

2002 ◽

Vol 32 (1-2) ◽

pp. 15-23 ◽

Cited By ~ 47

Author(s):

G. M. Peterson ◽

K. Boom ◽

S. L. Jackson ◽

J. H. Vial

Keyword(s):

Atrial Fibrillation ◽

Stroke Prevention ◽

Antithrombotic Therapy

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Recent Advances in Antithrombotic Therapy for Stroke Prevention in Patients With Atrial Fibrillation

Hospital Practice ◽

10.3810/hp.2013.02.1007 ◽

2013 ◽

Vol 41 (1) ◽

pp. 49-60

Author(s):

Joshua D. Lenchus

Keyword(s):

Atrial Fibrillation ◽

Stroke Prevention ◽

Antithrombotic Therapy ◽

Recent Advances

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Improving the Prescription of Oral Anticoagulants in Atrial Fibrillation: A Systematic Review

Thrombosis and Haemostasis ◽

10.1055/s-0038-1676835 ◽

2019 ◽

Vol 119 (02) ◽

pp. 294-307 ◽

Cited By ~ 10

Author(s):

Ruth Pritchett ◽

Danai Bem ◽

Grace Turner ◽

G. Thomas ◽

Joanne Clarke ◽

...

Keyword(s):

Atrial Fibrillation ◽

Systematic Review ◽

Medical Care ◽

Stroke Prevention ◽

Assessment Tool ◽

Peer Group ◽

Oral Anticoagulants ◽

Controlled Trials ◽

Computerized Decision Support ◽

Appropriate Prescription

Objective Oral anticoagulant (OAC) prescription for stroke prevention in atrial fibrillation (AF) patients frequently does not follow current guidelines, with underuse in patients at high risk of stroke and substantial overuse in those at low risk. This review aims to systematically evaluate the effectiveness of interventions to improve appropriate OAC prescription in eligible AF patients for stroke prevention. Methods Systematic review of controlled and uncontrolled studies published up to July 2017 with interventions designed to improve appropriate OAC prescription for stroke prevention in eligible AF patients (according to risk assessment tool or guidelines). Categorization of intervention types was pre-specified. The main outcome was change in proportion of eligible AF patients prescribed OACs for stroke prevention. Results Twenty studies conducted in 392 settings were included (cluster randomized controlled trials, controlled trials and uncontrolled before-after designs; n = 29,868 patients at baseline). Fifteen studies reported significant improvements in appropriate prescription of OACs in AF patients. All interventions with a persuasive element (8/8); all studies targeting health care professional (HCP) education or guideline/protocol implementation (7/7); and all medical care programs (4/4) achieved significant increases in appropriate OAC prescription. Computerized decision support interventions (3/5) and reviews of prescribing (2/4) were less likely to report significant improvements in appropriate OAC prescription. Conclusion Interventions designed to improve appropriate prescription of OACs in eligible AF patients for stroke prevention can be effective. Successful approaches include education of HCPs; implementation of local guidelines; interdisciplinary medical care programs educating both HCPs and patients and persuasive interventions utilizing peer-group experts. Protocol registration: PROSPERO (CRD42016039654).

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