Atrial Fibrillation Stroke Prevention: Expert Guidance for Primary Care Physicians

Many patients with atrial fibrillation (AFib) are not receiving any therapy to prevent stroke, and Geoffrey Barnes, MD, argues that primary care clinicians are well positioned to change that. In an analysis of more than 429 000 outpatients with AFib in the NCDR PINNACLE Registry, fewer than half of patients at high stroke risk were prescribed an oral anticoagulant.¹

In this interview, Barnes, a cardiologist and vascular medicine specialist at the University of Michigan Frankel Cardiovascular Center, explains that any patient with a history of AFib should have a conversation about stroke prevention. For many patients, that means an oral anticoagulant. For those whose bleeding history makes anticoagulation a poor choice, he points to left atrial appendage occlusion.²

The biggest barrier to treatment, he says, is bleeding or bruising. Some patients stop their anticoagulant on their own or after consulting a health care professional; others quietly take less, perhaps dosing only every other day, and end up undertreated.

He also challenges a common clinician habit: reducing the dose out of worry about bleeding. Barnes cautions that prescribing below the evidence-based, full therapeutic dose exposes patients to unnecessary stroke risk without actually reducing their bleeding risk. In the ORBIT-AF II Registry, roughly 1 in 10 patients received a lower-than-recommended dose of a direct oral anticoagulant, a practice associated with a higher risk of cardiovascular hospitalization.³

Finally, he highlights cost and access, noting that many patients cannot afford or obtain their medications, and urges clinicians across the health system to help patients work through these challenges.

Watch the full video for Barnes' view on where the biggest gaps in AFib stroke prevention lie and how primary care can help close them.

References:

1. Hsu JC, Maddox TM, Kennedy KF, et al. Oral anticoagulant therapy prescription in patients with atrial fibrillation across the spectrum of stroke risk: insights from the NCDR PINNACLE Registry. JAMA Cardiol. 2016;1(1):55-62. doi:10.1001/jamacardio.2015.0374

2. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2024;149(1):e1-e156. doi:10.1161/CIR.0000000000001193

3. Steinberg BA, Shrader P, Thomas L, et al. Off-label dosing of non-vitamin K antagonist oral anticoagulants and adverse outcomes: the ORBIT-AF II Registry. J Am Coll Cardiol. 2016;68(24):2597-2604. doi:10.1016/j.jacc.2016.09.966