Atrial fibrillation and stroke prevention: we can do better

Too many patients with atrial fibrillation (AF) and an elevated risk of stroke are missing out on appropriate long-term anticoagulation, and this puts them at unacceptable risk of catastrophic stroke and death. This makes early detection, use of validated stroke and bleeding risk assessment tools, and prompt initiation of anticoagulation essential. 

We need to better understand and explain the risk–benefit equation of using anticoagulants, and change the assessment of bleeding risk to considerations about how bleeding risk factors can be reduced. 

To support you and your patients, we have developed a suite of free CPD resources, to achieve the best possible clinical outcomes. These include:

• virtual and in-practice educational visiting – book your visit here 

• live and on-demand webinars and podcasts

• mini audit

• co-designed clinical guides and patient aids for use during appointments

• clinical summaries

What's happening in practice?

When direct-acting oral anticoagulants (DOACs) emerged over a decade ago, they largely replaced warfarin for stroke prevention in AF. These newer medicines offered comparable efficacy to warfarin with a lower incidence of intracranial haemorrhage, as well as a predictable dose response and no need for routine INR monitoring or dietary restrictions. It’s easy to understand why they became the preferred choice to warfarin (1). 

Yet, despite the availability of DOACs, current evidence shows that their use in practice is suboptimal, and as a result, many patients are missing out on potentially life-saving treatment.

Reasons for this under-treatment include concerns about bleeding risk, knowledge gaps about who and how to screen, lack of confidence regarding dose adjustments for renal impairment and multimorbidity and when to stop these medicines in the lead-up to surgery. 

Adherence challenges

Not only are some patients missing out entirely on anticoagulant therapy, but more than 40% of those who start DOAC therapy, discontinue within 2.5 years after initiation (2).

Several factors may contribute to discontinuation of DOAC therapy, including a lack of understanding of the condition, fear of potential side effects, and misconceptions about the necessity of treatment (3,4). Many patients face competing health priorities or experience treatment fatigue, especially if they are taking multiple medications for other conditions. Furthermore, the fear of bleeding sometimes over-rides concerns about stroke risk, even though the benefits of stroke prevention with anticoagulation almost always outweigh the risk of major bleeding.

Bridging the gaps: what’s next?

Healthcare professionals can reduce the burden of AF-related stroke by:

• using risk assessment tools appropriately to guide treatment decisions Risk scores for bleeding can help determine the risk–benefit balance of anticoagulant therapy and identify potentially correctable bleeding risk factors. 

• regularly reviewing treatment plans Stroke risk in AF is dynamic and can change over time due to shifts in comorbidities, medications and age. Annual stroke risk assessment is recommended to avoid a “set and forget” approach.

• supporting adherence with appropriate patient education Adequate patient education at the initiation of treatment is crucial. Health professionals should address fears about bleeding risks. Regular reviews and ongoing discussions about the necessity of continued treatment will help improve long-term adherence. Resources are being developed as part of our program to support these efforts: visit QHUB - Oral anticoagulants.

Taking a national program approach

Oral anticoagulants for atrial fibrillation is the fourth federally-funded national education program from the Quality Use of Medicines Alliance. The program is based on extensive formative research and engagement with people with lived experience and health professionals. Their insights have helped inform a broad suite of education activities and practical information.

These resources will help you feel more confident prescribing and managing anticoagulants, while ensuring your patients receive the best possible stroke prevention care.

Learn more: QHUB - Oral anticoagulants

For more free Quality Use of Medicines education, check out QHUB on Medcast