COMMENTARY

Fewer French Women With AF Are on Anticoagulants: Are They Really Undertreated?

John Mandrola

Disclosures

September 04, 2013

The title of the final press conference of the European Society of Cardiology (ESC) 2013 Congress caught my eye: an "Update on "Rhythmology" touched on four relevant clinical topics, but one stood out:

General Practitioners in France Undertreat Women with AF

Mixing the term undertreat with women tends to pique a lot of interest.

Before going further, I ask you to pause a minute and let the idea of what "undertreat" means exactly. You'll see what I mean at the end.

The abstract:

French physician Dr Pierre Sabouret presented data taken from a large (1.6-million) patient database during 2010–2011, including 1200 general practitioners. In this retrospective observational cross-sectional study, they used 14 274 patients in the analysis.

After excluding those with low stroke risk (CHA2DS2-VASc -0 or 1), the researchers discovered that only 48.1% of women were treated with anticoagulation, vs 52.6% of men (p<0.0001). More than 21% of women received only aspirin, which is counter to guideline-directed care. Breaking down the analysis by age revealed young women were nearly half as likely as men to be anticoagulated. The gender gap persisted in women >75 years old but was less pronounced, with older women being 33% less likely to have anticoagulation.

Dr Sabouret made this statement in the ESC press release:

"W  omen with AF receive less anticoagulation treatment than men despite the fact that they are at greater risk of stroke. The new CHA2DS 2-VASc score should be used more stringently, especially in women, to optimize their treatment. Treatment of all women with AF should be reviewed to ensure they are receiving anticoagulation if appropriate according to the CHA2DS2-VASc score."

In the question-and-answer session, which was spirited, he stayed on message: persistently emphasizing the importance of the CHA2DS2-VASc risk score.

Female gender confers added risk for stroke, he told the press audience. The discussant, Austrian physician Dr Helmut Puerenfellner, added, "More than 90% of AF patients over the age of 65 years meet criteria for anticoagulation."

Other questions focused on the "why" question. Here the study didn't help much. Dr Sabouret speculated it was due to under appreciation of the CHA 2DS2-VASc score. Again, he reiterated that the main message was that the CHA2DS2-VASc score is incorrectly applied.

When asked which physicians were responsible, Dr Sabouret did not blame only GPs. He remarked that both cardiologists and GPs in Europe underapplied the CHA2DS2-VASc.

I asked whether patient preferences might be playing a role. Perhaps French women feel differently about the benefit/burden trade-off of anticoagulation than do men? Dr Sabouret didn't think much of that theory. The problem isn't with the patients, he said. It was that physicians (all types) underestimate the stroke risk of female gender. Again, he called for better implementation of guidelines.

My thoughts:

This is a great topic. On the one hand, the data are clear that women with AF have a higher stroke risk than men. When I see a 70-year-old woman with AF, I worry about stroke, first and foremost. Talk to these women; ask them about their parents. Many will tell you their parents died of stroke. Given the strong heritability of AF, I wonder whether AF was the underlying cause. I think about helping them change the course of their disease. (Note: I realize that family history is not a part of CHA2DS2-VASc. I'm just telling you about things I think of in the exam room.)

Anticoagulation decisions are not that easy.

You know how I feel about telling patients what they need. No patient (woman or man) needs to take an anticoagulant. Trading an increased risk of bleeding for stroke prevention is a preference-sensitive decision. The job of a clinician is to help patients make the decision that best conforms to their goals.

I'm clear with at-risk patients about the net clinical benefit of anticoagulation, but I am also candid about the absolute risks as well.

And for discussing absolute risks, a decision aid is helpful. I would highly recommend the EP Mobile app, designed by my friend and colleague, Dr David Mann . Here's a screen shot of the CHA2DS2-VASc scoring system from the app.

Using nicely displayed real data helps me feel like I am improving decision quality.

For instance, that screen shot shows only a 2.2% annual stroke risk for a CHA2DS2-VASc score of 2. This brings me back to the question I asked in the conference. It's possible, likely even, that some female patients may see the 97.8% annual risk of not having a stroke as reassuring. In other words, for some, a 2.2% stroke risk is not worth the burden of anticoagulation.

Measuring the quality of AF care will take more than just measuring the number patients on anticoagulants. These are individual decisions that patients and physicians must make together.

This is why I would interpret such "undertreatment" data with caution.

We don't know why women were undertreated. We don't know if they were undertreated. I humbly suggest that "undertreat" may not be the right word.

My emphasis would be a little different from the French researchers.

I would emphasize the CHA2DS2-VASc score, for sure. But I would also use the gender-related CHA2DS2-VASc risk score to help improve decision quality.

JMM

 

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