Effect of Drug Interactions and Adherence on Coagulation Control of Patients Treated With Warfarin (original) (raw)

JAMA Cardiology, 2016

Abstract

In Reply We appreciate the interest McAlister took in our recent article in JAMA Cardiology1 regarding oral anticoagulation prescription in patients with atrial fibrillation (AF) across the spectrum of stroke risk in the American College of Cardiology National Cardiovascular Data Registry Practice Innovation and Clinical Excellence Registry. The author highlights some of our main findings, including that oral anticoagulant (OAC) prescription prevalence did not surpass 50%, even in high-risk patients with a CHADS2 score greater than 3 and a CHA2DS2-VASc score greater than 4. Much of the focus of our article was on the observed underuse and plateau of OAC prescription such that half of patients with AF at moderate to high risk for stroke did not receive guideline-adherent therapy. However, the author is correct to point out that almost 1 in 3 patients at the lowest risk of stroke, with CHADS2 and CHA2DS2VASc scores of 0, also received OAC prescription. We completely agree that the appropriate prescription of anticoagulation must take both underuse and overuse into account. In fact, in a recently published study2 also using the Practice Innovation and Clinical Excellence Registry, we observed practice patterns very consistent with those referenced by McAlister. Specifically, we assessed those patients with AF at the lowest risk of stroke. Despite a contemporary guideline class III indication against anticoagulant therapy (including those younger than 60 years) at that time, approximately 25% of young and otherwise healthy patients with AF with CHADS2 and CHA2DS2-VASc scores of 0 were prescribed OAC. Older age and higher body mass index were associated with more frequent OAC prescription after multivariable adjustment.2 Not everyone with AF should receive OAC, and stroke risk scores should be used to guide these decisions. Indiscriminate OAC use introduces more risks than benefits in these patients and violates the fundamental ethic of medicine, primum non nocere (ie, “first, do no harm”). We agree that pay-for-performance programs and even clinical research funding may not incentivize efforts to elucidate this behavior, but we think it is important to support further efforts to highlight overuse as an area of needed reform.

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