Abstract 2448: Mistakes in the Use of Amiodarone and Anticoagulation Management for Atrial Fibrillation: Why Do Cardiologists Deviate From Guidelines?
Introduction: Despite the availability of the 2006 ACC/AHA/ECS guidelines for the management of atrial fibrillation (AF), cardiologists’ recommendations vary regarding anticoagulation and amiodarone use. We examined the drivers for management decisions contrary to guidelines.
Methods: In an online survey, 464 cardiologists recommended treatment in 7 distinct AF patient scenarios. Computer manipulations of 22 independent patient variables yielded unique combinations; 3107 scenarios were reviewed. Each scenario was adjudicated by 2 blinded specialists based on ACC/AHA/ESC guidelines. Instances in which class I-indicated therapy had not been recommended and class III indications (contraindications) had been recommended were identified, and a subanalysis was performed to assess whether patient characteristics (symptom severity, type of AF, CHADS2 score) were drivers for guideline-variant recommendations regarding anticoagulation and amiodarone use.
Results: Anticoagulation was inappropriately recommended in 131/230 patients with a CHADS2 score of 0 (18% with permanent AF) compared with 99/230 patients with appropriate recommendations (ie, no anticoagulation; 11% with permanent AF) (P<0.05). Of the inappropriate recommendations, 72% of patients were symptomatic, while 79% with appropriate recommendations were symptomatic (P=NS). Inappropriate withholding of anticoagulation was seen in 119 scenarios (59% paroxysmal, 60% persistent, 74% permanent; P<0.05). Importantly, 81 patients with prior stroke or TIA and CHADS2 score >2 were not recommended warfarin (46% asymptomatic). Amiodarone was recommended inappropriately in 138 patients who were asymptomatic and in another 98 patients with paroxysmal AF at first-line therapy. Of the latter 98 patients, 80 had severe symptoms suggesting that symptomatology drove the inappropriate early use of amiodarone.
Conclusions: Cardiologists frequently deviate from established guidelines with regard to anticoagulation and amiodarone use for AF. Education is required to emphasize that CHADS2 score, rather than type of AF or symptomatology, should determine anticoagulation recommendations; amiodarone should be a second-line agent regardless of patient symptomatology.