Women and Seniors Still Undertreated for Afib-Related Stroke Prevention

Meghan Ross, Senior Associate Editor
Published Online: Wednesday, June 22nd, 2016
Retail clinicians should make sure that their female patients at high risk for atrial fibrillation-related stroke are on appropriate therapy, as new study results published in Journal of the American Geriatrics Society suggest that women aren’t prescribed blood thinners as often as men.
 
This retrospective study involved around 1500 adults aged 28 to 93 years with nonvalvular atrial fibrillation between March 2013 and February 2014. The patients were treated based on an atrial fibrillation decision support tool (AFDST) that considered quality-adjusted life expectancy and risk factors for stroke and hemorrhage.
 
The researchers found that treatment was discordant from AFDST-recommended treatment in 45% of women and 39% of men. In 44% of female cases, the women took aspirin or no therapy when oral anticoagulant therapy was recommended by AFDST.
 
“Women were 1.8 times as likely to be undertreated as men,” the researchers stated.
 
Lead study author Mark H. Eckman, MD, professor and director of the Division of General Internal Medicine and the Center for Clinical Effectiveness at University of Cincinnati Medical Center, told Contemporary Clinic that the research team was disappointed, but not surprised, that these results matched what has been seen nationally in terms of women being undertreated with blood thinners to prevent stroke related to atrial fibrillation.
 
The research team similarly discovered that seniors were often undertreated and only taking aspirin as their sole antithrombotic agent. Nurse practitioners and physician assistants should be aware that elderly patients who only take aspirin instead of oral anticoagulant therapy face a greater risk of bleeding and are probably seeing little or no help in stroke prevention from the aspirin.
 
In the past, prescribers have cited that they see fall risk, dementia, and nonadherence as barriers to their willingness to prescribe warfarin to elderly patients. However, the current researchers argued that given the higher risk of atrial fibrillation-related stroke in elderly adults, the benefits of oral anticoagulant therapy outweigh the risks.
 
Overall, 37% of patients who should have been prescribed oral anticoagulant therapy were only taking aspirin or no therapy at all.
 
“We found that the reason for discordant treatment in women and the elderly was under-use of blood-thinning therapy, while in men and younger patients, a larger proportion of discordance was due to overtreatment,” Dr. Eckman noted.
 
Those aged 31 to 50 years were most likely to be overtreated.
 
Dr. Eckman’s take-home message for practitioners was that women face higher risks for atrial fibrillation-related stroke even after controlling for other risk factors, such as hypertension, diabetes, or heart failure. In addition, women’s risk for death from atrial fibrillation is underappreciated.
 
“Therefore, we must be especially vigilant to make sure that we are aggressive enough in prescribing appropriate blood thinning therapy (oral anticoagulants) in women at high risk of atrial fibrillation-related stroke, using tools such as the CHA2DSVAS2c to assess stroke risk,” Dr. Eckman said.
 
Atrial fibrillation is expected to affect 3 million Americans by 2020. By 2050, around half of Americans with atrial fibrillation will be aged 80 years or older. 


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