Anticoagulation Therapy in NVAF


Peter Salgo, MD; Ralph J. Riello III, PharmD, BCPS; Jaime E. Murillo, MD; Juvairiya Pulicharam, MD; and Gary M. Besinque, PharmD, FCSHP, comment on the role of anticoagulation in patients with nonvalvular atrial fibrillation and explore common challenges in treating patients with available therapies.

Peter Salgo, MD: You alluded to something just now that I think is important because everything has risk and benefit. Sure, a risk of embolic stroke with atrial fibrillation is a significant risk. What is the role of anticoagulation here? What do people worry about?

Ralph J. Riello III, PharmD, BCPS: All good questions. Sometimes I think we forget that the role of anticoagulation in atrial fibrillation is to prevent a stroke. Of course, we want that to come with as minimal risk as possible. But, again, it’s important to emphasize that we’re preventing stroke or systemic embolism here. I can manage a bleed or even a major intracranial hemorrhage. I can manage that. But that next stroke could potentially be debilitating. It could affect one’s quality of life, or it could be fatal.

Peter Salgo, MD: Something that you just said whizzed by. I want to challenge that. Maybe we all want to challenge that? You said, “I can manage an intracranial hemorrhage.” How?

Ralph J. Riello III, PharmD, BCPS: We’ll get into reversal of anticoagulants later in the discussion, but the rule of thumb is that I’m using anticoagulants to prevent a stroke or systemic embolism from happening. That’s going to incur a risk of bleed. That’s why that risk versus benefit discussion is important, as well as education with the CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke) and the CHA2DS2-VASc (vascular disease, age 65-74 years, sex category) scores. You really have to have those thoughtful discussions with patients about these comorbidities. “Your real risk is this. Would you like some anticoagulation to prevent that from happening?”

Peter Salgo, MD: There’s a theory out there, from some doctors, of “I’ll just give you a little anticoagulation, and maybe we’ll just prevent a little bit of your stroke.” Does that make sense? My sense is that there are a lot of patients out there who are undertreated.

Jaime E. Murillo, MD: Absolutely, and there are enough data to show that. Just last year, there was a paper in Circulation that showed that 12% of patients are underdosed. They think a patient shouldn’t receive a specific dose. “It’s too high for these patients.” But actually, there’s no real reason for that. Four percent of those patients are also in the category of patients for whom the dose should have been reduced because of the renal dysfunction, for instance. The problem is that for the patients who are underdosed, their risk of stroke actually gets higher. It sounds paradoxical, but “Hey, you’re on a lower dose, so your risk should be lower.” Actually, the risk of ischemic stroke is higher.

Juvairiya Pulicharam, MD: I just want to add that education is very important for patients and primary care physicians. When we did a registry for patients with atrial fibrillation, that’s the one thing that stood out. Many patients believe that they don’t need anticoagulation. They’re afraid to take any anticoagulation because of bleeding events. Primary care physicians are also not really sure. They’re hearing about the new agents, and warfarin, and which one for which patient. Even though we feel it should be out there, this is not new information, that they need anticoagulation. It’s really a big gap.

Peter Salgo, MD: Let me put something to bed. Every day I see patients in the intensive care unit. I see them preoperatively. They say, “I’ve got atrial fibrillation. My doctor put me on aspirin.” I notice the shocked look on your faces. Is that a good idea?

Jaime E. Murillo, MD: Aspirin is very good for the prescriber. It does nothing for the patient. Let’s just make that clear.

Peter Salgo, MD: It doesn’t impact your stroke risk at all.

Jaime E. Murillo, MD: It makes the doctor feel better, if that’s what they’re looking for, but it definitely won’t have any...

Gary M. Besinque, PharmD, FCSHP: It doesn’t hold a candle to anticoagulation.

Peter Salgo, MD: Nothing is instead of anticoagulation. It’s good for your heart, inflammation, and ischemic heart disease but not for stroke.

Gary M. Besinque, PharmD, FCSHP: Right.

Jaime E. Murillo, MD: And not in everybody.

Peter Salgo, MD: I think we pretty much put that one to rest?

Juvairiya Pulicharam, MD: Yes.

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