AFib-Associated Stroke Prevention Prescribing Beliefs Vary Markedly Between Medical Disciplines
VANCOUVER, BC—Neurologists, internists and cardiologists differ markedly in their prescribing beliefs when it comes to the prevention of ischemic stroke due to atrial fibrillation, according to survey results presented at the 68th Annual AAN Meeting.
“Attitudes toward anticoagulant agents vary between specialties,” reported Lester Y. Leung, MD, Director of the Stroke and Young Adults Program at Tufts Medical Center in Boston, MA, and coauthors, in a poster presentation. “Vascular neurologists tended to be more concerned with the risk of hemorrhagic complications as compared to the internists and cardiologists, as shown by their avoidance of the combination of aspirin and warfarin, and their selection of NOACs [novel oral anticoagulants] based on reduced risk of ICH [intracerebral hemorrhage].”
Oral anticoagulants are frequently prescribed to prevent atrial fibrillation-associated ischemic stroke, but factors influencing prescription practices by different types of physicians “are not well understood,” the coauthors wrote. To evaluate prescriber beliefs that affect anticoagulant prescribing patterns across disciplines, the researchers conducted an anonymous online multiple-choice questionnaire to 128 physicians (n=58 internists, 54 vascular neurologists, and 16 cardiologists).
“When prescribing anticoagulation, most (66%) were primarily concerned with the efficacy of ischemic stroke prevention (60% of internists, 69% of cardiologists, 70% of vascular neurologists; P=0.5, [n.s.]),” the coauthors wrote. “This concern surpassed safety profile, cost, and east of reversal of anticoagulation for all specialties.”
Results showed neurologists were more likely to believe warfarin alone sufficed for patients with atrial fibrillation and coronary artery disease without stents or to avoid prescribing the combination (P=0.00028). Internists and cardiologists were more likely to prescribe the combination of aspirin and warfarin in this setting (45% and 56%, respectively).
“All specialties were equally likely to be unaware that only dabigatran has demonstrated superiority compared to warfarin in ischemic stroke prevention in clinical trials,” the coauthors wrote. “Both cardiologists (38%) and vascular neurologists (50%) were somewhat more likely to identify that rivaroxaban and apixaban have not demonstrated superiority compared to warfarin in ischemic stroke prevention, as compared to internists (21%; P=0.005).”
Only 10% of internists and 19% of cardiologists surveyed reported that reduced risk of ICH was the primary advantage of NOACs, compared to half (50%) of vascular neurologists, the team reported. Cardiologists were significantly more concerned about cost (81%) than internists (45%) or vascular neurologists (59%; P=0.0012), they wrote.
“The field of anticoagulation is rapidly changing, and more shifts in medication selection may follow the development of effective antidotes for reversal of the anticoagulant effect of NOACs,” the authors noted.