Using an Atrial Fibrillation Decision Support Tool (AFDST), investigators determined that 45% of women and 39% of men in the study population were not being treated according to the tool’s recommended treatments to prevent stroke resulting from atrial fibrillation (AF).
Investigators wanted to achieve a better understanding of the appropriateness of antithrombotic therapy for thromboprophylaxis in women and elderly adults.
So they studied a cohort of individuals with AF to determine whether they were treated according to recommendations.
According to lead author Mark Eckman, MD, of the University of Cincinnati in Ohio, under treatment of patients with AF is a national problem.
And ironically, “[W]omen have a higher risk of AF-related stroke,” he said, “controlling for other risk factors such as hypertension, diabetes, congestive heart failure, yet women are being under treated.”
The team retrospectively studied 1585 adults aged 28 to 93 with nonvalvular AF or flutter cared for in an ambulatory setting in the University of Cincinnati Health primary care network.
The primary care doctors were testing the computerized AFDST, which uses patient information and characteristics to help with decisions about anticoagulant therapy to prevent stroke in AF patients.
The AFDST calculates for the individual patient the risk of AF-related stroke and major bleeding while taking blood thinning therapy. Based on this information, the AFDST makes suggestions for the best treatment to prevent AF-related stroke.
Demographics
Of the 1585 study participants, 46% were women.
Half of the participants were receiving some form of oral anticoagulant, primarily warfarin (39%), 36% were on aspirin only, and 11% were receiving other oral anticoagulants.
The investigators noted a trend in the study population toward lower levels of oral anticoagulant use in women (48%) as compared to men (52%), but the trend was not statistically significant (P=0.06).
Results
The AFDST recommended oral anticoagulation for 87% of the participants, aspirin for 4%, and no antithrombitic therapy for 9%.
Patients' antithrombotic therapy was concordant with the AFDST recommendation in 58% of the participants.
Of the 42% for whom therapy was discordant with the AFDST, 37% were receiving aspirin only or no antithrombotic therapy when the tool recommended oral anticoagulation; 2% were receiving no antithrombotic therapy when the tool recommended aspirin; and 3% were receiving aspirin or oral anticoagulation when the tool recommended no antithrombotic therapy.
And as mentioned above, current treatment was discordant from recommended treatment in 45% of women and 39% of men (P=0.02).
Forty-four percent of women were under treated, receiving aspirin only when oral anticoagulation was recommended, compared with 31% of men who were under treated (P<0.001). Women were 1.8 times as likely to be under treated as men.
"Doctors need to realize we have mental biases that women are healthier and at lower risk of stroke,” Dr Eckman said.
“We think women are at lower risk and we ignore warning signs,” he continued. “Thus, when we are making decisions for blood thinning therapy for patients with atrial fibrillation, we need to remember that women are at higher risk and we need to make sure we treat them aggressively enough to prevent stroke."
Overall, the use of oral anticoagulants did not differ significantly by age, with 55% of the patients 85 years and older receiving anticoagulation and 49% of the patients younger than 85 receiving it (P=0.13).
In 35% of the older population, treatment was discordant with recommendations compared with 43% in the younger (P = 0.009). Similar proportions in the younger and older groups were undertreated (P=0.30).
According to investigators, one surprising finding was that the proportion of patients receiving discordant treatment was larger in the younger group than in the over-85 group. They attributed this largely to overtreatment in the 31 to 50 age group.
Dr Eckman and colleagues published these findings in Journal of the American Geriatrics Society.
The research was supported in part by grants from Bristol-Myers Squibb/Pfizer Education Consortium, Pfizer Medical Education Group, Informed Medical Decisions Foundation, and the National Institutes of Health/National Center for Advancing Translational Sciences.
