AF Management: Are Clinicians in Agreement?

Medscape/ACC Survey

Megan Brooks

Disclosures

May 30, 2019

Editorial Collaboration

Medscape &

Cardiologists and other clinicians approach the management of patients with atrial fibrillation (AF) differently, according to a survey of 400 full-time practicing physicians, including cardiologists, neurologists, and primary care physicians (PCPs), and 100 nurse practitioners and physician assistants (NPs/PAs). The survey was conducted by Medscape in collaboration with the American College of Cardiology (ACC). According to the cardiologists surveyed, persons with AF make up about one quarter of all patients seen each month, and most are treated with a direct oral anticoagulant (DOAC)/novel oral anticoagulant (NOAC). Of note, 20% of cardiologists surveyed do not monitor DOACs; however, other physicians and clinicians are more likely to refer to anticoagulation clinics for monitoring.

Additional insights from the survey include:

  • Apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), and edoxaban (Savaysa) are the top-prescribed anticoagulants over warfarin.

  • Cardiologists and neurologists differ in their use of bleeding risk scores before prescribing DOACs.

  • Cardiologists are less likely than other clinicians to use coagulation assays for monitoring AF patients taking DOACs.

  • Half of clinicians would consult a neurologist about AF patients with a discrete neurologic finding or an overt neurologic deficit.

  • A third of clinicians cite limited or controversial efficacy data as the reason for not implanting or limiting the implantation of a left atrial appendage (LAA) occluder in patients with AF.

The US Centers for Disease Control and Prevention (CDC) estimates that between 2.7 and 6.1 million people in the United States have AF, a number that is expected to grow with the aging of the population. Currently, about 9% of people over age 65 and about 2% of people younger than 65 have AF.

DOACs Rule

Approximately 60% of healthcare professionals surveyed manage AF with a DOAC. Among them, cardiologists are more likely to treat with a DOAC (70%) compared with neurologists (63%), PCPs (52%), and NPs/PAs (56%).

Only a minority of patients (25% overall) with AF are referred to anticoagulation clinics for monitoring. General cardiologists (18%) refer about twice as many patients for anticoagulation as do cardiac electrophysiologists (8%). Notably, ob/gyns send a large proportion of their patients (59%) for monitoring.

Before prescribing a DOAC, 42% of cardiologists surveyed use a bleeding risk score such as HAS-BLED always or most of the time to assess a patient's overall risk for bleeding, as do 38% of PCPs and 49% of NPs/PAs. Neurologists were the least likely to use a bleeding risk score, with 46% saying they rarely or never do.


 

About 40% of all survey respondents use activated partial thromboplastin time and prothrombin time at least sometimes to monitor patients taking a DOAC. Cardiologists, however, are least likely to use activated partial thromboplastin time or prothrombin time, with more than 70% indicating that they rarely or never use these tests. Other coagulation assays (ie, plasma drug concentrations, ecarin clotting time, dilute thrombin time, and anti-factor Xa levels) are not frequently used by any practitioner surveyed.


 

In general, healthcare professionals responding to the Medscape/ACC survey strongly agree on the need for long-term anticoagulant therapy in patients with AF lasting >24 hours.

There is less certainty, however, on the need for long-term anticoagulation for episodes >6 minutes but <1 hour (about two thirds of all physicians and NPs/PAs strongly agree that there is a need) or for multiple episodes of short duration (<20 sec).


 

Of note, 55% of all clinicians (66% of cardiologists, 71% of NPs/PAs) would change their stance on who needs long-term anticoagulation if a patient had a CHA2DS2-VASc score of 1 versus 2 or higher.

Triple Therapy After PCI With Stenting

Cardiologists surveyed estimate that more than a quarter (28%) of their patients with AF have undergone percutaneous coronary intervention (PCI) with stent placement, and about half of them have been advised to take triple therapy (anticoagulation [vitamin K antagonist (VKA) or DOAC] plus dual antiplatelet therapy [DAPT; aspirin or P2Y12 inhibitor]). Other clinicians are less likely to recommend triple therapy.

For patients with AF and a CHA2DS2-VASc score ≥2 who have received a drug-eluting stent, most clinicians favor a DOAC (typically apixaban) plus aspirin 81 mg and clopidogrel (Plavix), with cardiologists most in favor of this approach. About 70% of all physicians strongly agree that a proton pump inhibitor should be prescribed for patients with AF and stents who are prescribed triple therapy and have a history of gastrointestinal bleeding.

When adding a single antiplatelet drug to a VKA or a DOAC, 54% of cardiologists surveyed pick clopidogrel and 37% pick aspirin. These two are also favored by other clinicians.

Creatinine Clearance Cutoffs

About half (49%) of all respondents consider a creatinine clearance (CrCl) level <30 mL/min to be a contraindication to starting or continuing a DOAC in AF patients at risk for stroke. Cardiologists are the exception; they are as likely to name a CrCl <15 mL/min as the cutoff (34%).

Among all physicians, apixaban is most likely to be recommended over warfarin for patients with AF and a CrCl <50 mL/min (63%), particularly among cardiologists (90%). Cardiologists' next top pick is rivaroxaban (55%), followed by dabigatran and edoxaban (around 30%).


 

Heart Valve Patients

When faced with a new patient with AF and a mechanical prosthetic heart valve, about 60% of all clinicians surveyed would prescribe a VKA, commonly without aspirin. Cardiologists are more likely to prescribe a VKA plus aspirin (41%) than are PCPs (25%), neurologists (16%), or NPs/PAs (20%).

Among clinicians who prescribe a VKA plus aspirin, 90% of cardiologists favor this approach regardless of the patient's history of stroke or transient ischemic attack, as do 69% of neurologists and PCPs and 75% of NPs/PAs.

Cardiologists and other clinicians most often prescribe VKAs and non-VKA anticoagulants for patients newly diagnosed with AF and with a bioprosthetic heart valve and at risk for stroke. The next most popular choice among all clinicians is either a VKA plus aspirin or a DOAC plus aspirin.

For AF patients at risk for stroke with a ≥6-month history of transcatheter aortic valve replacement, physicians most often prescribe a DOAC (32%) or VKA alone (24%), with cardiologists most often choosing a DOAC (48%). Almost 20% of physicians and 30% of NPs/PAs are not sure which drug they would prescribe.

Ablation and LAA Occlusion/LAA Procedures

Cardiologists and other clinicians weigh a number of factors when deciding whether to refer a patient with AF for ablation therapy. For cardiologists, the top three are medication intolerance (85%), lack of response to antiarrhythmic drugs (84%), and recurrent paroxysmal symptomatic AF (86%). These are also the top factors considered by neurologists and PCPs. Most cardiologists (81%) also factor in quality of life and symptoms.

Nearly 90% of cardiologists but less than 40% of neurologists surveyed would refer a symptomatic patient <75 years who is not controlled on medication to catheter ablation.


 

Most cardiologists (73%) would also refer a symptomatic patient who does not want to take antiarrhythmic drugs for catheter ablation, compared with 45% of neurologists and just over half of PCPs and NPs/PAs. About two thirds (67%) of cardiologists say they never or rarely refer patients who are asymptomatic on antiarrhythmic drugs for catheter ablation.

LAA Closure

A little more than half of all clinicians surveyed, including 70% of cardiologists, said their institution performs percutaneous LAA occlusion procedures for patients with AF. The most common indications for these procedures are high bleeding risk (57%), history of bleeding on a DOAC (58%), absolute contraindication to a DOAC (53%), and poor patient compliance with anticoagulation (44%).

There is wide variation in antithrombotic protocols in the initial phase (0-6 months) following occluder implantation in AF patients with no contraindication to DOAC and no LAA leak during follow-up transesophageal echocardiography.

The two most common protocols are OAC and antiplatelet therapy for a limited period (eg, up to 6 weeks or 6 months), followed by antiplatelet monotherapy (25% of cardiologists and 22% of all physicians) and OAC for 6 weeks followed by DAPT for 6 months (25% of cardiologists, 19% of all physicians). The latter protocol is more commonly used in cardiac electrophysiologists' institutions (40%) than in general cardiologists' (17%).

The chief reasons for avoiding or limiting LAA occlusion in patients with AF vary. The top two are procedural risk (cited by 48% of physicians overall) and patient comorbidities (cited by 43% of physicians overall). Other reasons cited include high cost/reimbursement issues and limited/controversial efficacy data compared with DOACs and no anticoagulation.

Survey Methodology and Demographics

The Medscape/ACC survey on management of atrial fibrillation and cardiovascular risk was administered between August 8, 2018 and October 19, 2018. Cardiologists were recruited from ACC and Medscape memberships, and all other clinicians were recruited from Medscape memberships.

Medscape and ACC asked more than 400 full-time practicing physicians, including cardiologists, neurologists, and PCPs, and 100 NPs/PAs, for their views on diagnosis and treatment of AF. Outcomes show that in a typical month, cardiologist survey respondents see about 70 patients with AF compared with about 24 for PCPs and neurologists and 37 for NPs/PAs.

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