Survey of confidence in use of stroke and bleeding risk calculators, knowledge of anticoagulants, and comfort with prescription of anticoagulation in challenging scenarios: SUPPORT-AF II study

Half of patients with atrial fibrillation (AF) and elevated stroke risk do not receive anticoagulation (AC). Explanations for undertreatment may relate to provider lack of confidence with or knowledge of the CHA₂DS₂-VASc stroke calculator, unfamiliarity with direct oral anticoagulants (DOACs), or uncertainty about use of AC after bleeding events or other challenging patient scenarios. We surveyed cardiology and primary care providers (PCPs) within a large healthcare system to investigate prescriber knowledge, confidence, and comfort prescribing AC for AF in challenging scenarios. Of 112 providers invited, 70 (63%) completed our survey. Compared with non-responding providers, responding providers had fewer years in practice and more often worked in a university setting. Responding providers were moderately or very confident with use of CHA₂DS₂-VASc calculator (90%). Cardiology providers reported substantial knowledge about DOACs (72%) compared with PCPs (33%). Both provider groups reported reluctance prescribing AC when presented with challenging patient scenarios (% providers agreeing with AC): three falls over 6 months (36%), 2 weeks after resolved gastrointestinal bleed (21%), 4 weeks after intracranial bleeding (9%), in a patient consuming five alcoholic drinks per day (44%). All providers were moderately or very confident with using the CHA₂DS₂-VASc calculator, but only cardiology providers reported substantial knowledge about DOACs. Our providers were reluctant to prescribe AC after bleeding and in other common situations where use of AC may be appropriate. Education of PCPs about DOACs and development of guidelines to address challenging patient scenarios may improve AC prescription rates in patients with AF.