The anticoagulation choices of internal medicine residents for stroke prevention in non-valvular atrial fibrillation.
OBJECTIVE
To explore the oral anticoagulation (OAC) prescribing choices of Canadian internal medicine residents, at different training levels, in comparison with the Canadian Cardiovascular Society (CCS) guidelines for non-valvular atrial fibrillation (NVAF).


METHODS
Cross-sectional, web-based survey, involving clinical scenarios designed to favour the use of non-vitamin K antagonists (NOACs) as per the 2014 CCS NVAF guidelines. Additional questions were also designed to determine resident attitudes towards OAC prescribing.


RESULTS
A total of 518 internal medicine responses were analysed, with 196 postgraduate year (PGY)-1s, 169 PGY-2s and 153 PGY-3s. The majority of residents (81%) reported feeling comfortable choosing OAC, with 95% having started OAC in the past 3 months. In the initial clinical scenario involving an uncomplicated patient with a CHADS2 score of 3, warfarin was favoured over any of the NOACs by PGY-1s (81.6% vs 73.9%), but NOACs were favoured by PGY-3s (88.3% vs 83.7%). This was the only scenario where OAC choices varied by PGY year, as each of the subsequent clinical scenarios residents generally favoured warfarin over NOACs irrespective of level of training. The majority of residents stated that they would no longer prescribe warfarin once NOAC reversal agents are available, and residents felt risk of adverse events was the most important factor when choosing OAC.


CONCLUSIONS
Canadian internal medicine residents favoured warfarin over NOACs for patients with NVAF, which is in discordance with the evidence-based CCS guidelines. This finding persisted throughout the 3 years of core internal medicine training.
Department of Medicine, Queen's University, Kingston, Ontario, Canada.
Nathaniel
N
Moulson
Section of Cardiology, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
William F
WF
McIntyre
Section of Cardiology, Department of Internal Medicine, University of Calgary, Calgary, Alberta, Canada.
Zardasht
Z
Oqab
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Payam
P
Yazdan-Ashoori
Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Kieran L
KL
Quinn
Department of Medicine, Western University, London, Ontario, Canada.
Erik
E
van Oosten
Department of Medicine, Queen's University, Kingston, Ontario, Canada.
Wilma M
WM
Hopman
Department of Medicine, Queen's University, Kingston, Ontario, Canada.
Adrian
A
Baranchuk
D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D002170:Canada; D003430:Cross-Sectional Studies; D004503:Education, Medical, Graduate; D005260:Female; D006801:Humans; D007388:Internal Medicine / Q000193:education*; D007396:Internship and Residency; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D020521:Stroke / Q000517:prevention & control*; D011795:Surveys and Questionnaires; D014859:Warfarin / Q000008:administration & dosage / Q000627:therapeutic use*
D000925:Anticoagulants; D014859:Warfarin
INTERNAL MEDICINE; MEDICAL EDUCATION & TRAINING