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SDOH in NVAF FAQs
Frequently Asked Questions About Addressing Social Determinants of Health in NVAF

Released: May 26, 2022

Expiration: May 25, 2023

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In this commentary, Keith C. Ferdinand, MD, FACC, FAHA; David S. Kountz, MD; and Laura Ross, PA-C, CLS, answer audience questions about the treatment and management of patients receiving anticoagulant therapy for nonvalvular atrial fibrillation (NVAF) from the webinar “The Biggest Risk to Cardiovascular Health: Addressing Social Determinants of Health in NVAF.”

What is your experience with home international normalized ratio (INR) monitors to help manage warfarin therapy?

Keith C. Ferdinand, MD, FACC, FAHA:
Simply having a monitor at home will not overcome the barriers related to adherence, including low health literacy, an inconsistent diet (especially regarding green leafy vegetables), or if patients do not understand how to take their medicines. Patients will still be at risk for having complications as you adjust the warfarin. This is where the direct oral anticoagulants (DOACs) have the advantage.

David S. Kountz, MD:
I would work in collaboration with our social workers to get home testing for appropriate patients.

What strategies do you use to get patients with NVAF on DOACs?

Keith C. Ferdinand, MD, FACC, FAHA:
Most of the newer DOACs have patient assistance programs for patients who have no insurance or who have limited insurance. Although patients can start DOACs using a 1-month free trial card, working together with a pharmacist (academic or community) to help your patients get long-term access to medicines with cards and coupons at a lower cost is a good strategy. Fortunately, most Medicare plans will cover the DOACs.

David S. Kountz, MD:
I think emphasizing the convenience of DOACs—fewer laboratory monitoring requirements and fewer food and drug interactions—is important, and engaging the family with the patients consent is a clever way to have an ally for care in the home. In our system, we are fortunate as we have a “Social Determinants of Health” module in our electronic medical records, which allows providers to locate community resources for things like medication assistance. Healthcare providers in large organizations can work together with physician groups to provide a powerful voice for medication assistance. For example, I work for a health system with 17 hospitals that is among the largest care providers in our state, and I think that the people who receive letters from providers will take more notice of them when they write as a group.

Laura Ross, PA-C, CLS:
The unsung heroes in this health journey are our pharmacist colleagues, who are a resource for patients at their individual pharmacy or at their medical facility. Pharmacists are familiar with the nuances of a patient’s particular insurance. A nurse or social worker working closely with the primary care physician can also help navigate the programs available in the community.

Healthcare providers getting more involved with national organizations can also be helpful. The American College of Cardiology has a legislative session and pick topics that are very pertinent to my practice. Recently, they met with our legislature to consider having physician associates/physician assistants and nurse practitioners order cardiac rehabilitation. The next week our senator cosponsored a bill in the senate for that. These changes can happen, but they do have to happen at a higher level. 

Do you think that the history of using minorities in unethical research has prevented these patients from receiving treatment? How can a healthcare provider combat that kind of suspicion?

Keith C. Ferdinand, MD, FACC, FAHA:
This is a big problem and I confront it head on with cultural humility. I tell my patients that I recognize that bad things have happened in medicine in the past and that their misgivings are real. I acknowledge that the new medication may or may not have been well studied in their population. Then I explain the benefit of the new therapy that I am offering, despite limitations in diversity in clinical trials, how it would help them, and that it is easier to take. I think that message resonates with the patient.

How do DOACs work and why is INR monitoring not needed with DOACs? After a patient has started on a DOAC, how long does it take for the medication to become therapeutic?

Keith C. Ferdinand, MD, FACC, FAHA:
DOACs work by inhibiting clotting factor Xa that is critical for the generation of thrombin and clot formation in the coagulation cascade. Inhibition of factor Xa results in decreased thrombin-induced clot formation and, hence, the name “direct oral anticoagulants.” By contrast, warfarin is a vitamin K antagonist that inhibits vitamin K epoxide reductase complex 1 activation of vitamin K, resulting in depletion of vitamin K in the body and a reduction in vitamin K–dependent clotting factor synthesis. Warfarin affects the prothrombin time measured by the INR test meter. Since DOACs interfere with all coagulation assays, the INR is not used to measure therapy. Normally, we measure therapy by giving patients the DOAC and looking at how it works.

DOACs are indicated for pulmonary embolisms, deep vein thrombosis, and so on, and the onset is rapid. If the patient experiences excessive bleeding or bruising, there are ways to attempt reversal but I would simply stop it as the offset is also rapid. After a day or so, the DOACs are gone. DOACs can be removed in the same way when a patient requires a surgical procedure or dental extractions. By contrast, warfarin has a slow onset so we have to place the patients on heparin for about 3 days. The offset is also prolonged, so if the person is bleeding, we may give vitamin K or the bleeding can be excessive and continue for days.

Which anticoagulant is the best for atrial fibrillation?

Keith C. Ferdinand, MD, FACC, FAHA:
All DOACs are very similar. I think the renal dosing favors apixaban if the creatinine clearance (CrCl) is <15 mL/min, but for most patients with normal renal function, there is no significant difference, and to date, there have not been any head-to-head trials with the various DOACs. For people weighing ≤60 kg or are aged 80 years or older, there is some favoring of apixaban in those populations at a lower dose (2.5 mg twice daily). The rivaroxaban dose can be adjusted to 15 mg vs 20 mg if the CrCl is between 15 and 50 mL/min. For moderate or severe renal impairment (CrCl 15-50 mL/min), edoxaban is used at 30 mg daily vs 60 mg. I think these medicines are equally effective and easier to manage than warfarin; however, when we take access and social determinants into account, we need to make sure that the person is able to get those medicines.

David S. Kountz, MD:
I think the key element of the question is that all are superior to warfarin in terms of ease of use and monitoring, but we do have to pay attention to whether the patient is able to have the prescription filled and is available long term. I think the best medicine is the one that is affordable.

What strategies help with compliance with warfarin and talking to the patient about a DOAC?

Keith C. Ferdinand, MD, FACC, FAHA:
I have a warfarin clinic at Tulane Medical Center in New Orleans, Louisiana, and I find that ensuring adherence to therapy and compliance with changes in warfarin is quite cumbersome. When patients have low INRs, we make an adjustment and then the INR becomes too elevated. Patients will eat some greens or drink alcohol, resulting in wide swings in the INR. So I would make that extra effort to work with patients, to get resources to them while educating them about DOACs, that is, not having to do the INR every week, not having the extensive and unexpected INR swings, and that they may be within therapeutic range more consistently.

David S. Kountz, MD:
People do not want to deal with the consequence of a stroke, and they are concerned about that outcome and the impact it would have on their family. I ask patients to look at what they have done in the past and the knowledge they have gained while receiving warfarin to determine changes we can make to their treatment (eg, make the blood draw easier). I think it is helpful to include their partner in the conversation and to remind patients of what is on the other side if they are not compliant.

Do you address social determinants of health in primary nonadherence?

Keith C. Ferdinand, MD, FACC, FAHA:
I think what we are addressing is the need to educate patients so that they become a partner in their care. The patients who understand why they are taking the medicine—it is not just because you are suggesting it but because you want to help them prevent strokes and early death—those patients will be more motivated to be adherent.

What resources do you use to explain atrial fibrillation?

Keith C. Ferdinand, MD, FACC, FAHA:
As a cardiologist, I prefer CardioSmart.org, a patient information platform from the American College of Cardiology with easy-to-print infographics and text explaining atrial fibrillation and what it means. I think it is important to sit down with patients and provide high-level coaching using the appropriate literacy level. Hand the material to them and use a yellow marker to point to things vs saying, “Here’s a link to CardioSmart.” I do not think it is enough to simply suggest a website when the patient is older or has lower technology literacy.

David S. Kountz, MD:
As a noncardiologist, I also love CardioSmart.org, and the infographics are great. I also think that it is important to take the time to provide that additional level of support by reviewing the information and answering their questions before the patients leave the office.

Are the newer DOACs preferable to dabigatran, and in what situation would you use one over the other?

Keith C. Ferdinand, MD, FACC, FAHA:
The best DOAC is the one that the person will take. Dabigatran, a direct thrombin inhibitor, was approved by the FDA in 2010 and does have drug–drug interactions (ie, permeability glycoprotein P-gp inhibitors, P-gp inducers, and antacids), and perhaps the evidence base related to cardiovascular events is not as robust as we see with the other DOACs. But I certainly will not suggest that if healthcare professionals prefer to use dabigatran and look at those interactions that they are doing the wrong thing.

How can researchers include more diverse participant populations in future studies?

David S. Kountz, MD:
There are many important goals and considerations, including having diverse, trained researchers from academia or community facilities who can participate in the study, having bilingual staff and who match the background of patients who are potential subjects, having a deep understanding of the historical issues that marginalized populations have had to deal with in research, and having a sense of grace and patience. You cannot go into a community center with a great new study and expect, after years of neglect or other issues, that a group of people will automatically jump into a research study.

Can we extrapolate these findings to the Middle East population regarding their specific social determinants of health and how we treat them?

Keith C. Ferdinand, MD, FACC, FAHA:
I know that the social determinants of health have an impact regardless of where you live. We recognize that things like race and ethnicity are difficult to generalize. Across the globe, there are people who will be described as White or Black who live in the Middle East. Therefore, it is not race/ethnicity but where people live that affects their social determinants of health. If people do not have access or if they have risk factors that are not under control, then I think our whole discussion remains the same.

What are examples of cultural competence training that would be beneficial in a cardiology practice to try to help with the social determinants of health? What have you done in your own practice?

Laura Ross, PA-C, CLS:
An awareness of what is happening within our healthcare system and to our patients is the first step. For a language barrier, using an online translation tool or incorporating other team and family members can make communication with the patient easier.

David S. Kountz, MD:
Topics related to cultural competence, implicit bias, and microaggressions are becoming common in the education of physicians and probably other healthcare professionals. Therefore, a great resource would be your local medical school, nursing school, and other schools educating healthcare professionals.

Your Thoughts?
In your practice, which strategies have you implemented to address social determinants of health in your patients with NVAF? Answer the polling question and join the discussion in the comments box below.

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