Reasons for omitting anticoagulant treatment in patients with atrial fibrillation: an audit of patient records in general practice.

Background: Anticoagulant treatment is recommended for most patients with atrial fibrillation. Yet, register studies show a persisting treatment gap, which may lead to preventable strokes. This study aimed to explore the reasons for omitting anticoagulant treatment in patients with atrial fibrillation.

Methods: We performed a comprehensive audit of electronic patient records in Danish general practice, including 12 clinics served by 39 general practitioners. All patients with atrial fibrillation, prevalent on 1 January 2023 and receiving no anticoagulant treatment, were identified using data from nationwide health registers. Patient records were reviewed retrospectively, covering the period 1 January 2001-1 January 2023. Information on care trajectories, follow-up patterns, decisions on anticoagulant treatment and reasons for omission were extracted and summarised using descriptive statistics.

Results: In a representative sample of patients with atrial fibrillation receiving no anticoagulant treatment (n = 166), the absence of treatment was based on clinical decisions explicitly noted in the patient records in 93.4% of cases. In 34.3% of non-users, anticoagulants were deselected due to a low risk of stroke and no treatment indication, and 59.1% represented clinical decisions made in areas with no firm guideline recommendations. Reasons for anticoagulant treatment omission included minimal atrial fibrillation burden, left atrial appendage closure, palliative care, risk-benefit considerations and patient preference. However, in 6.6% of patients, the absence of treatment reflected unjustified or outdated decisions. For patients with atrial fibrillation receiving no anticoagulant treatment, care trajectories were characterised by contacts across healthcare sectors. For 64.4% of patients, the most recent contact for atrial fibrillation occurred in the hospital setting, while 30.7% had theirs in general practice. Most follow-up consultations were planned in general practice, but 59.0% had no follow-up plan. A decision on anticoagulant treatment was explicitly documented in the electronic patient record (at least once since diagnosis) for 94.6% of patients, with 22.3% revised in the past year.

Conclusion: This study found that most anticoagulant treatment omissions in patients with atrial fibrillation were supported by documented clinical reasoning, suggesting that the extent of inappropriate undertreatment may be lower than expected. Nevertheless, optimising care pathways could facilitate timely anticoagulation for some patients with atrial fibrillation.