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.
Triple antithrombotic therapy in patients with atrial fibrillation undergoing coronary artery stenting: hovering among bleeding risk, thromboembolic events, and stent thrombosis
