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Only 45% of Singaporean patients with atrial fibrillation and CHA2DS2-VASC score > 1 receive anticoagulation. Using the ACTS questionnaire, we demonstrated that patients have a positive attitude towards anticoagulation, and are willing to follow their physician's treatment advice. This contrasts with our practical impression of physicians’ attitude. We decided to objectively assess how well physicians anticipate patients’ preferences on anticoagulation.

Design and method:

We described a virtual patient as a 76 years old lady with CHA2DS2-VASC score 5. We asked 89 physicians if and how they would provide anticoagulation for this patient. The physicians were told to anticipate this patient's answers to the ACTS questionnaire. This uses a 5 point Likert scale to assess the degree to which subjects agree with statements that describe perceived risk and benefit of anticoagulation treatment. Finally, physicians’ answers were compared to real patients’ answers using a two- sided Mann Whitney U test.


68 of 89 physicians advocate anticoagulation. Of these, 9 (13%) opted for acetyl salicylate. 76 complete physician questionnaires were compared with answers given by 129 patients. Physicians gave more negative answers than patients. They expected patients to perceive both benefit and burden to be higher. All responses were significantly different, with two exceptions: “is anticoagulation burdensome?” and “did your life change positively through anticoagulation?” were answered with an equally indifferent value by both groups.


In a similar patient cohort from Singapore, Lim and coworkers identified risk of bleeds, or patients’ preferences as most common cause to withhold anticoagulation in atrial fibrillation. Our own patient group, however, was willing to opt for anticoagulation provided minimum information regarding indication, risk and likely benefits was provided. They were generally ignorant on these matters when first approached, and completely reliant on their physicians as sole information source. Local physicians tended to disregard international evidence based guidance based on a more negative perception of risk and benefits of anticoagulation. The low anticoagulation rate in Singaporean patients is due to physicians’ attitude towards the treatment. Improvement strategies should target factual knowledge of guidance and underlying evidence, and advertise patient's true preferences.

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