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Net Clinical Benefits of Guidelines and Decision Tool Recommendations for Oral Anticoagulant Use among Patients with

Anand R Shewale1, Jill T Johnson2, Chenghui Li1

  • 1Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, AR.

Journal of Stroke and Cerebrovascular Diseases : the Official Journal of National Stroke Association
|October 21, 2015
PubMed

Insights

Oral anticoagulant (OAC) use concordant with most guidelines improved net clinical benefit for atrial fibrillation (AF) patients. CHEST guidelines showed the highest benefit, while CHA2DS2-VASc aids didn't consistently outperform CHADS2 aids.

Area of Science:

  • Cardiology
  • Clinical Decision Making
  • Pharmacotherapy

Background:

  • Existing guidelines (CHEST, ESC, AHA) and decision tools (LaHaye, Casciano) provide recommendations for oral anticoagulant (OAC) use in atrial fibrillation (AF).
  • The net clinical benefit (NCB) of OAC prescribing aligned with these decision aids has not been comprehensively compared.

Purpose of the Study:

  • To compare the net clinical benefit (NCB) of oral anticoagulant (OAC) prescribing that was concordant with established clinical practice guidelines and decision tools for patients with atrial fibrillation (AF).

Main Methods:

  • A retrospective cohort study utilizing LifeLink claims data from 2001-2013.
  • Net clinical benefit (NCB) was defined as adverse events (thromboembolic and major bleeding) prevented per 10,000 person-years.
  • Cox proportional hazard models were employed to assess the adjusted relative risk of AF adverse events associated with concordant OAC use.

Main Results:

  • The study included 15,129 AF patients (33,512 person-years).
  • The American College of Chest Physicians (CHEST) guidelines demonstrated the highest NCB (30.07), while European Society of Cardiology guidelines showed the lowest (7.38).
  • Unadjusted analysis indicated decreased AF adverse event risk with concordant OAC use for CHEST, Casciano, and LaHaye tools, but these findings lacked statistical significance after multivariate adjustment.

Conclusions:

  • Concordant OAC use with most decision aids, excluding the LaHaye tool, resulted in a positive net clinical benefit (NCB).
  • Decision aids based on the CHA2DS2-VASc score did not consistently yield superior NCB compared to CHADS2-based aids.
  • Recommending OAC for patients with a CHA2DS2-VASc score of 1 was associated with a reduced NCB when other factors remained constant.
Abstract

Keywords:
Atrial fibrillationconcordancedecision toolguidelinenet clinical benefit

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