How do family medicine residents choose an anticoagulation regimen for patients with nonvalvular atrial fibrillation?

• Published in: Primary health care research & development 2017-09, Vol.18 (5), p.472-481
• Main Authors: Yazdan-Ashoori, Payam, Oqab, Zardasht, McIntyre, William F., Quinn, Kieran L., Oosten, Erik van, Hopman, Wilma M., Baranchuk, Adrian
• Format: Article
• Language: English
• Subjects: Adult; Age; Aged; Aged, 80 and over; Anticoagulants; Anticoagulants - therapeutic use; Antihypertensive Agents - therapeutic use; Atrial Fibrillation - drug therapy; Canada; Cardiac arrhythmia; Cardiology; Costs; Decision Making; Diabetes; Drug dosages; Family medical history; Family Practice; Female; Heart failure; Humans; Hypertension; Hypertension - drug therapy; Internship and Residency; Male; Medicine; Middle Aged; Patients; Risk assessment; Risk Factors; Stroke; Stroke - prevention & control; Students, Medical - psychology; Studies
• ISSN: 1463-4236; 1477-1128
• DOI: 10.1017/S1463423617000196

Aim To examine the choices Canadian family medicine residents make for oral anticoagulation (OAC) for patients with nonvalvular atrial fibrillation (AF). AF increases the risk of strokes. An important consideration in AF management is risk stratification for stroke and prescription of appropriate OAC. Family physicians provide the vast majority of OAC prescriptions. We administered a survey to residents in multiple Canadian family medicine training programmes. Questions explored the experiences and attitudes towards risk stratification and choices of OAC when presented with standardized clinical scenarios. In each scenario, a novel oral anticoagulant (NOAC) would be the preferred treatment according to the contemporary Canadian and European guidelines. Findings A total of 247 residents participated in the survey. Most used the congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, stroke or TIA (2 points) (81%) and congestive heart failure, hypertension, age ≥ 75 (2 points) or age 65-74 (1 point), diabetes mellitus, stroke or TIA, vascular disease including peripheral arterial disease, myocardial infarction, or aortic plaque, sex (female) (67%) risk stratification schemes while the preferred bleeding risk stratification scheme was hypertension, abnormal liver or renal function, stroke, bleeding, labile international normalized ratio, elderly (age ≥ 65), drugs or alcohol (84%). In the clinical scenarios, residents generally preferred warfarin in favour of NOACs, independent of training level. Residents ranked the risk of adverse events and the cost to the patient as their most and least important consideration when prescribing OAC, respectively. Therefore in patients with nonvalvular AF, Canadian family medicine residents prefer warfarin in comparison with NOACs despite the latest Canadian and European guideline recommendations. This knowledge gap may be enhanced by multiple factors, including a sometimes magnified fear of adverse events and a rapidly changing landscape in stroke prophylaxis.