Wesley O’Neal, MD, on Anticoagulation Therapy for AFib With Dr Wesley O’Neal
Bleeding events, including stroke, are a common concern for patients with atrial fibrillation (AF) who are taking anticoagulation therapy. New research shines a light on whether early cardiologist involvement affects the rate of oral anticoagulant prescription fills and whether that reduces the risk for stroke.
Consultant360 recently spoke with the lead author on the study, Wesley O’Neal, MD, who is a cardiology fellow at Emory University School of Medicine in Atlanta, Georgia.
Consultant360: Can you tell us a little bit about your study and how it came about?
Wesley O’Neal: Recent studies have suggested that early cardiology involvement shortly after a diagnosis of AF is associated with more patients receiving anticoagulant therapies, which are important to prevent strokes in patients who have AF. Data from the US Department of Veterans Affairs have demonstrated a favorable influence of early cardiology involvement on prescription fills for these important medications, and patients who saw a cardiology provider also were less likely to experience stroke. Using a large administrative claims database consisting of commercially insured patients and Medicare recipients, we aimed to examine whether early cardiology involvement influences oral anticoagulant prescription fills and whether a reduced risk of stroke also was present in a cohort representative of real-world AF care.
C360: Was there any correlation between anticoagulant use and bleeding or stroke risk?
WO: We observed that patients who saw a cardiology provider within 6 months of their AF diagnosis were less likely to experience stroke events, a devastating complication of AF that is prevented with oral anticoagulant therapies. Additionally, these patients were more likely to fill prescriptions for oral anticoagulant therapies, but this did not equate to a higher risk of bleeding, an important complication of these medications. Patients who saw cardiology providers were more likely to fill prescriptions for newer oral anticoagulant agents that have a lower risk of bleeding compared with warfarin, and this possibly explains why a higher bleeding risk was not observed despite higher fill rates for oral anticoagulants among those who saw a cardiology provider.
C360: Can you talk more about the safety associated with patients on anticoagulant therapy who are being cared for by a cardiologist vs primary care?
WO: Our study showed that patients who saw a cardiology provider were more likely to fill an oral anticoagulant prescription without an increased risk of bleeding. A major concern with prescribing oral anticoagulant therapies in patients with AF is the complication of bleeding. The similar risk of bleeding possibly was related to the fact that patients who saw a cardiology provider were more likely to fill newer oral anticoagulant agents that have more favorable side effect profiles, including a reduced risk of bleeding, compared with warfarin. Overall, these data likely reflect that cardiology providers were more likely to prescribe oral anticoagulant therapies that have a more favorable bleeding profile, rather than their care being considered safer compared with primary care physicians.
C360: How does the provider specialty relate to medication adherence?
WO: Our study was not able to address if cardiology involvement shortly after AF diagnosis improved adherence to oral anticoagulant therapies. We merely examined whether a prescription fill for anticoagulant therapies occurred within the 3 months prior to 6 months after AF diagnosis. Our group is actively examining this question in other research projects.
C360: How will the results of your study affect our audience?
WO: The data suggest that cardiology involvement shortly after AF diagnosis is able to improve prescription fills for oral anticoagulant therapies, a guideline-recommended strategy to reduce the risk of stroke in patients who have AF. Also, cardiology involvement was associated with a reduced risk of stroke, without an increased risk of bleeding. Overall, the data suggest that newly diagnosed cases of AF may benefit from early referral to a cardiologist to positively influence outcomes in patients who have AF. The findings are relevant to all providers who care for patients with AF, including cardiology and primary care providers.
C360: What else should our audience know about anticoagulation therapy?
WO: The decision to start these therapies is often weighed against the risk of bleeding, and a shared decision model between provider and patient is needed prior to the initiation of oral anticoagulant therapies. Regardless of your provider specialty (cardiology vs primary care), patients with AF should be made aware of their stroke risk and the possible need for oral anticoagulant therapies.
O'Neal WT, Sandesara PB, Claxton JS, et al. Provider specialty, anticoagulation prescription patterns, and stroke risk in atrial fibrillation [published online March 10, 2018]. J Am Heart Assoc. https://doi.org/10.1161/JAHA.117.007943.