@article {Apentenge002275, author = {Patricia Apenteng and Saverio Virdone and John Camm and Keith A A Fox and Jean-Pierre Bassand and Alexander G G Turpie and Seil Oh and Marianne Brodmann and Frank Cools and Antonio C P Barretto and J{\o}rn Nielsen and Sylvia Haas and Gloria Kayani and Karen S Pieper and Ajay K Kakkar}, title = {Determinants and clinical outcomes of patients who refused anticoagulation: findings from the global GARFIELD-AF registry}, volume = {10}, number = {1}, elocation-id = {e002275}, year = {2023}, doi = {10.1136/openhrt-2023-002275}, publisher = {Archives of Disease in childhood}, abstract = {Objective There is a substantial incidence of stroke in patients with atrial fibrillation (AF) not receiving anticoagulation. The reasons for not receiving anticoagulation are generally attributed to clinician{\textquoteright}s choice, however, a proportion of AF patients refuse anticoagulation. The aim of our study was to investigate factors associated with patient refusal of anticoagulation and the clinical outcomes in these patients.Methods Our study population comprised patients in the Global Anticoagulant Registry in the FIELD (GARFIELD-AF) registry with CHA2DS2-VASc>=2. A logistic regression was developed with predictors of patient anticoagulation refusal identified by least absolute shrinkage and selection operator methodology. Patient demographics, medical and cardiovascular history, lifestyle factors, vital signs (body mass index, pulse, systolic and diastolic blood pressure), type of AF and care setting at diagnosis were considered as potential predictors. We also investigated 2-year outcomes of non-haemorrhagic stroke/systemic embolism (SE), major bleeding and all-cause mortality in patients who refused versus patients who received and patients who did not receive anticoagulation for other reasons.Results Out of 43 154 AF patients, who were at high risk of stroke, 13 283 (30.8\%) did not receive anticoagulation at baseline. The reason for not receiving anticoagulation was unavailable for 38.7\% (5146/13 283); of the patients with a known reason for not receiving anticoagulation, 12.5\% (1014/8137) refused anticoagulation. Diagnosis in primary care/general practitioner, Asian ethnicity and presence of vascular disease were strongly associated with a higher risk of patient refusal of anticoagulation. Patient refusal of anticoagulation was associated with a higher risk of non-haemorrhagic stroke/SE (adjusted HR (aHR) 1.16 (95\% CI 0.77 to 1.76)) but lower all-cause mortality (aHR 0.59 (95\% CI 0.43 to 0.80)) compared with patients who received anticoagulation. The GARFIELD-AF mortality score corroborated this result.Conclusion The data suggest patient refusal of anticoagulation is a missed opportunity to prevent AF-related stroke. Further research is required to understand the patient profile and mortality outcome of patients who refuse anticoagulation.No data are available. Data and analysis presented in this study was derived from the GARFIELD-AF registry, based on accrued eCRF data from patients diagnosed in 2010-2016 and followed-up to 2018. Aggregated data can be shared upon reasonable request and analysis plan to Saverio Virdone (Svirdone@tri-london.ac.uk).}, URL = {https://openheart.bmj.com/content/10/1/e002275}, eprint = {https://openheart.bmj.com/content/10/1/e002275.full.pdf}, journal = {Open Heart} }