Research from the ACC's PINNACLE Registry® indicates that in the United States, anticoagulation therapy for eligible patients with atrial fibrillation (AF) is suboptimal and varies widely from practice to practice. Global anticoagulation patterns, especially in emerging markets, are less well understood. Even in developed countries, understanding the perceptual and systemic issues underlying suboptimal anticoagulation rates requires further investigation.

To develop a broader understanding of the causes of gaps in anticoagulation for eligible patients, the ACC launched Project TREAT-RISK (TRansnational Evaluation of AF Therapy for the Reduction of ISchemic StroKe). Results from TREAT-RISK will help inform the ACC's AF-focused quality improvement programs, including awareness building, education, and tools.

The first stage of TREAT-RISK included a major transnational survey of AF treatment patterns in June and July 2012, using CardioSurve, the ACC’s member survey panel. A total of 1,134 cardiologists completed the survey in June to July 2012. Respondents are practicing cardiologists in the United States (n = 232), Brazil (n = 261), China (n = 145), Germany (n = 125), India (n = 218) and the United Kingdom (n = 153). All respondents used the same online instrument, allowing for valid comparisons proportionally and across countries.

AF Care Patterns: Similarities and Differences

AF treatment is a global concern for practicing cardiologists. Nearly all those surveyed report currently treating patients with AF: a high of 99% of cardiologists in the United Kingdom, 97% in the United States, 96% in Germany, and 95% in Brazil, China, and India. AF patient prevalence was consistent across country, practice setting, and gender.

Cardiologists in all six countries report that they prescribe warfarin or another anticoagulant for the most of their eligible AF patients, with the highest perception that appropriate patients are being prescribed anticoagulants in the United States (82% of eligible patients on average) and the lowest in China (58.1%). In the United States and United Kingdom, 27% and 24% of cardiologists respectively stated that they prescribe an anticoagulant for 100% of their eligible patients.

In all countries, a strong majority of providers stated that balancing stroke prevention and bleeding is their primary objective when contemplating an anticoagulation strategy, though considerable minorities in Germany (27%), Brazil (20%), and the United States (16%) replied that ischemic stroke prevention is the primary objective. Minimizing bleeding risk was most important to Indian (7%) and Chinese (7%) providers. Cardiologists in India and China were also least likely to prescribe an anticoagulant for patients over age 75 (only 47% and 43%, respectively, reporting that they "always" or "frequently" anticoagulate these patients). Cardiologists in Germany (93%), the United Kingdom (92%), and the United States (88%) were far more likely to always or frequently anticoagulate patients over age 75, followed by cardiologists in Brazil (65%).

Across all countries, most cardiologists (72%) would consider switching patients from warfarin to a novel oral anticoagulant. Stroke prevention efficacy (57%) and bleeding risk (52%) were selected as two of the "most important" factors considered when switching patients from warfarin to a novel oral anticoagulant, followed by ease of use (39%). (Respondents were able to select multiple factors as "most important.") Stroke prevention efficacy was most important to cardiologists in the United States and United Kingdom.

New Therapies and Cost Concerns

Many of the issues with anticoagulation using warfarin are at least generally understood: safety, bleed risk, patient preference, and stroke prevention efficacy. The introduction of novel oral anticoagulants has added cost as a further consideration.

Willingness to prescribe a novel oral anticoagulant drops considerably, across all countries when cost is considered: from 72% when cost is not a factor to 17% when it is. Cost is a more central concern in India, Brazil, and the United States. This finding is perhaps to be expected, as cardiologists report that patients in India and Brazil are most likely to pay out of pocket for an anticoagulation treatment while the government is the primary payer in Germany in the United Kingdom. Patients in the United States and China typically pay for treatment themselves, in conjunction with government and private.

Control over anticoagulation options in the care setting is another factor impacting the introduction of new anticoagulants. Nearly all cardiologists (87%) have some level of control over anticoagulation options and nearly half (47%) report a "high level" of control.

Next Steps

The ACC will continue to release findings from the TREAT-RISK Project and from this transnational survey as they become available. Issues of balancing stroke risk against bleeding risk, perceptions of bleeding risk, and the impact of comorbidities and other attendant medication therapies also surfaced in the survey findings and should prove a rich vein for continued investigation.

The ACC thanks Boehringer Ingelheim, Inc. for their founding sponsorship of Project TREAT-RISK.

Keywords: Quality Improvement, Stroke, Warfarin, Comorbidity, Atrial Fibrillation, Patient Preference, Awareness, United States

< Back to Listings