Relative importance of benefits and risks associated with antithrombotic therapies for acute coronary syndrome: patient and physician perspectives.
BACKGROUND
In acute coronary syndrome (ACS), antithrombotic therapies prevent thrombotic events, but also increase bleeding risk. Knowledge is limited about how patients and physicians balance these benefits and risks.


OBJECTIVE
To quantify US patient and physician preferences for outcomes associated with antithrombotic therapies in ACS.


METHODS
Two independent web-based surveys were conducted using best-worst scaling in board-certified cardiologists and adult patients hospitalized within the last 5 years due to heart attack and who used aspirin or prescription antithrombotic therapies. Participants selected best and worst of three possible outcomes across a series of questions. Outcomes included death, various levels of stroke, myocardial infarction (MI), and bleeding. Data were analyzed using a maximum difference model employing random-parameters logit. Relative importance of each outcome was estimated relative to death.


RESULTS
Patients (n = 206) and physicians (n = 273) who met face validity requirements, viewed death and nonfatal major disabling stroke as nearly equivalent and most important outcomes to avoid. Relative to death and disabling stroke, physicians considered nondisabling stroke, all nonfatal bleeding, and mild MI all as least important to avoid, while patients considered all bleeds, except major bleeding requiring transfusion, as least important to avoid. Physicians considered severe MI equivalent to 0.92 (0.02 SE) deaths. Patients (∼0.35 [0.04] deaths) and physicians (∼0.64 [0.05] deaths) had different views for nonfatal moderate stroke. Patients viewed nonfatal major bleeding requiring transfusion ∼0.13 (0.02) deaths, and nonfatal heart attack ∼0.09 (0.02) deaths.


CONCLUSIONS
US patients and physicians agree on the relative importance of avoiding death, disabling stroke and bleeding without transfusions. Differing perspectives on bleeding requiring transfusions, MI, and moderately disabling stroke suggest that patients and physicians may have different benefit-risk preferences. Transparent discussion between physicians and patients in ACS treatment shared decision-making seems warranted, although limitations of survey methodology and cultural differences compared with US participants should be considered.
Department of Epidemiology, Janssen Research & Development , Titusville, NJ , USA.
Zhong
Z
Yuan
Bennett
B
Levitan
Paul
P
Burton
Christine
C
Poulos
A
A
Brett Hauber
Jesse A
JA
Berlin
D054058:Acute Coronary Syndrome / Q000150:complications / Q000188:drug therapy*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D002309:Cardiology; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D019538:Health Care Surveys; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D009203:Myocardial Infarction / Q000209:etiology / Q000517:prevention & control*; D057240:Patient Preference / Q000706:statistics & numerical data*; D010820:Physicians; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D018570:Risk Assessment; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D014481:United States
D005343:Fibrinolytic Agents; D010975:Platelet Aggregation Inhibitors; D001241:Aspirin
Acute coronary syndrome; Antithrombotic therapy; Best; Conjoint analysis; Myocardial infarction; Stated preferences; Stroke; worst scaling