Relative importance of benefits and risks associated with antithrombotic therapies for acute coronary syndrome

Abstract

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.

Findings:
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.

Conclusion:
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.