ORIGINAL ARTICLE

Perception of the Risk of Stroke and the Risks

and Benefits of Oral Anticoagulation for
Stroke Prevention in Patients With Atrial
Fibrillation: A Cross-Sectional Study
Mohammad Hijazi, MD; Sami Aljohani, MD; Fahad Alqahtani, MD;
Zakeih Chaker, MD; Muhammad Al Hajji, MD; Ahmad Al Hallak, MD;
and Mohamad Alkhouli, MD

Abstract

Objective: To assess the perception of the risk of stroke and the risks and benefits of oral
anticoagulation (OAC) in patients with atrial fibrillation (AF).
Patients and Methods: Consecutive patients with chronic AF who presented for an outpatient
cardiology visit or were admitted to a noncritical care cardiology ward service from September 15
through December 20, 2017, were invited to participate in this survey. Participants were asked to
estimate their stroke risk without OAC and bleeding risk with OAC using a quantitative risk scale. The
reported values were compared with subjectively estimated risks derived from the CHA2DS2-VASc and
HAS-BLED scores. Similarly, we compared patient perception of the stroke risk reduction afforded
with OAC compared with what is reported in the literature.
Results: A total of 227 patients were included in the analysis. The mean
SD CHA2DS2-VASc score
was 4.3
1.6, and HAS-BLED score was 2.3
1.2. Atrial fibrillation was paroxysmal in 53.3% and
persistent/permanent in 46.7%. There was a negligible correlation between patient perceived and
estimated risk of stroke (r¼0.07; P¼.32), and bleeding (r¼0.16; P¼.02). Most patients overestimated
their risks of stroke and bleeding: 120 patients (52.9%) perceived an annual stroke risk greater than
20%, and 115 (53.5%) perceived an annual bleeding risk with OAC greater than 10%. Most patients
(n¼204; 89.9%) perceived that OAC would reduce their annual stroke risk by at least 50%.
Conclusion: Perceived risks of stroke and bleeding are markedly overestimated in most patients with
AF. Further research is needed to discern the root causes and to identify effective methods of bridging
this alarming disparity.
ª 2018 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2019;nn(n):1-9

S
troke prevention is a cornerstone in
the management of patients with
atrial fibrillation (AF). Current guide-
lines recommend lifelong oral anticoagula-
tion (OAC) to reduce the risk of ischemic
stroke in patients with a CHA2DS2-VASc
(congestive heart failure/left ventricular ejec-
tion fraction 40%, hypertension, age 75
years, diabetes mellitus, stroke/transient
ischemic attack/thromboembolism history,
vascular disease, age 65-74 years, female
sex) score of at least 2.1 However, long-
term OAC carries a significant risk of
bleeding and is associated with considerable
cost, lifestyle changes, and strict compliance
requirements.1 Hence, patient understanding From the Division of Car-
diology, West Virginia
of the role of OAC in stroke prevention and University, Morgantown.
its accompanied risks and benefits is key.
Nonetheless, several studies have reported
that patients with AF have major gaps in
knowledge of their condition, the treatment
they are taking, and the potential alternatives
despite being treated for AF for several
years.2-4 We conducted a cross-sectional
study at a tertiary academic center to assess
patient perception of the risks and benefits

Mayo Clin Proc. n XXX 2019;nn(n):1-9 n https://doi.org/10.1016/j.mayocp.2018.08.043 1

www.mayoclinicproceedings.org n ª 2018 Mayo Foundation for Medical Education and Research

of OAC for stroke prevention in the setting
of AF, and we compared patient perceived
and estimated annual risks of stroke and
bleeding.
PATIENTS AND METHODS
Study Design, Setting, and Participants
The study was conducted at Ruby Memorial
Hospital, the largest teaching hospital for
West Virginia University School of Medicine.
From September 15 through December 20,
2017, we invited consecutive patients with
AF presenting to a cardiology clinic (80%)
or admitted to a low-acuity nonecritical
care inpatient medicine/cardiology service
(20%) to participate in an interview assess-
ing their understanding of stroke prevention
in AF and the risks and benefits associated
with OAC. After informed consent was ob-
tained, trained research personnel conducted
brief structured interviews with the patients
at the end of their clinic visit in the outpa-
tient setting and once they were clinically
stable in the inpatient setting. Demographic
and clinical data were extracted from elec-
tronic medical records after the interview.
The person conducting the interview was
blinded to the clinical information at the
time of the interview. The institutional re-
view board of Ruby Memorial Hospital
approved this study.
Study End Points and Questionnaire
Structure
We hypothesized that there is a significant
gap in patient understanding of the stroke
risk associated with AF and the risks and
benefits of OAC for stroke prevention. How-
ever, there are no validated questionnaires to
specifically assess this issue. Therefore, we
developed a questionnaire in collaboration
with a behavioral scientist with experience
in qualitative research methods and cross-
sectional study design. The questionnaire
was intended to be simple and intuitive for
patients at a sixth-grade level of education
and included 7 questions inquiring about
the patient’s knowledge of the increased
stroke risk with AF, their estimation of the
annual stroke risk without prevention, risk
n n
2 Mayo Clin Proc.
MAYO CLINIC PROCEEDINGS
reduction with OAC, risk of bleeding while
receiving OAC, whether they are taking
OACs, reasons for taking or not taking
OACs for stroke prevention, and their
awareness of the different options for stroke
prevention in the setting of AF.
For a more quantitative assessment we
asked patients to estimate their annual risk
of stroke without prevention and the risk
reduction in stroke and the risk of bleeding
with OAC use. For this, we provided multi-
ple choices of customized risk categories.
These categories were carefully developed
using the following methods: (1) Annual
risk of stroke: The CHA2DS2-VASc score is
the most-used risk score for stroke risk pre-
diction in patients with AF. The maximum
annual stroke risk estimated by the
CHA2DS2-VASc score is 12.2% for a score
of 9. We expected that some patients will
overestimate their stroke risk. Hence, we
used the following stroke risk categories in
the questionnaire: 1% to 5%, 6% to 10%,
11% to 20%, 21% to 50%, and greater than
50%. The former 3 categories corresponded
with CHA2DS2-VASc scores of 1 to 4, 5 and
6, and 7 or greater, respectively
(Supplemental Table 1, available online at
http://www.mayoclinicproceedings.org). The
latter 2 categories do not correspond with a
CHA2DS2-VASc score but were created to pro-
vide patients with a full spectrum of options to
indicate their own perception of stroke risk
(from 1% to 100%). (2) Annual risk of
bleeding while taking OACs: The following
risk categories were used in the survey: 1%
to 3%, 4% to 6%, 7% to 10%, and greater
than 10%, corresponding to HAS-BLED (hy-
pertension, abnormal renal/liver function,
stroke, bleeding history or predisposition,
labile international normalized ratio, elderly
[age 65 years], drugs/alcohol concomi-
tantly) scores of 1, 2 and 3, 4 and 5, and 6
or greater, respectively (Supplemental
Table 2, available online at http://www.
mayoclinicproceedings.org). (3) Effective-
ness of OAC for stroke prevention: OAC
with warfarin reduces the risk of ischemic
stroke by 50% to 65%.5 The following choices
were then provided to patients for them to
estimate the effectiveness of OAC in reducing
XXX 2019;nn(n):1-9 https://doi.org/10.1016/j.mayocp.2018.08.043
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RISK PERCEPTION IN PATIENTS WITH AF
stroke: 10%, 30%, 50%, 70%, and 90%. Clin-
ical data collected from patient medical re-
cords included demographic characteristics,
clinical risk factors, socioeconomic status,
and all the elements required to calculate the
CHA2DS2-VASc and HAS-BLED scores.
Statistical Analyses
Continuous data are presented as mean

SD, and categorical data are presented as
count (percentage). For categorical data,
the association between patient perception
of stroke risk and estimated risk scores for
stroke and the association between patient
perception of annual risk of bleeding on
OAC and the estimated risk scores for
bleeding were assessed using the Pearson
c2 test or the Spearman rank correlation
coefficient. Correlation coefficients were
interpreted as follows: negligible correlation,
0.0-0.3; low correlation, 0.3-0.5; moderate
correlation, 0.5-0.8; and strong correlation,
0.8-1.0.4 Analyses were performed using
IBM SPSS Statistics for Windows, Version
24.0 (IBM Corp), and all the tests were
2-sided with a significance level of P¼.05.
Predictors of False Risk Perception. To
assess the possible association of certain clin-
ical and demographic factors with patients’
inaccurate (false) perceptions of their stroke
and bleeding risks, patients were grouped
into (1) those who accurately estimated their
risks, (2) those who had inaccurate estima-
tion of their risks (false perception), and
(3) those who had severe inaccurate estima-
tion of their risks (severe false perception).
False risk perception was defined as
choosing a risk category that is different
than what is predicted by CHA2DS2-VASc
and HAS-BLED scores. Severe false risk
perception was defined as choosing a risk
category that is at least 2 categories different
than what is predicted by the CHA2DS2-
VASc and HAS-BLED scores. The following
elements were then entered into univariate
and multivariate regression models: age, sex,
level of education, CHA2DS2-VASc score,
HAS-BLED score, duration of AF, history of
bleeding, and history of stroke.
Mayo Clin Proc. n XXX 2019;nn(n):1-9 n https://doi.org/10.1016/j.mayocp.2018.08.043
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Validation of the Survey Instrument. The
study cohort (n¼227) was randomly divided
into a derivation set (n¼114) and a valida-
tion set (n¼113) to examine the validity of
the study’s questionnaire. The outcome of
the prediction models was false risk percep-
tion (inaccurate assessment) of actual risk
score (CHA2DS2-VASc and HAS-BLED).
Prediction models were developed using
multivariable logistic regression analyses.
Variables included in the logistic regression
analysis included age, sex, level of education,
history of bleeding, and CHA2DS2-VASc and
HAS-BLED scores. The model predictive
performance (discrimination value) was
assessed using the C-statistic (area under the
receiver operating characteristic curve) on
the validation set.
RESULTS
A total of 287 patients participated in the
study, of whom 60 (20.9%) were not aware
of the increased stroke risk with AF and
were thus excluded. This yielded a study
cohort of 227 patients. Mean
SD patient
age was 72.2
10.2 years, and 125 patients
(55.1%) were men. Providers of AF care
were cardiologists in 94.3% of participants
(n¼214). Mean
SD CHA2DS2-VASc score
was 4.3
1.6 and HAS-BLED score was
2.3
1.2. Most patients (n¼158; 69.6%) had
a high school or less level of education
(Table 1). Atrial fibrillation was paroxysmal
in 121 patients (53.3%) and persistent/perma-
nent in 106 (46.7%). Most patients (40.5%)
had a history of bleeding, with gastrointes-
tinal bleeding being the most common
bleeding location (53.0%). Other bleeding lo-
cations included musculoskeletal in 8.7%,
genitourinary in 7.6%, intracranial in 6.5%,
pulmonary in 4.3%, and others in 38%.
Correlation Between Patient Perception and
Estimated Outcomes
Annual Risk of Stroke. There was a negli-
gible correlation between patient perceived
and estimated risk of stroke (r¼0.07;
P¼.32). The estimated annual stroke risk
based on the CHA2DS2-VASc score was 1%
to 5%, 6% to 10%, and 11% to 20% in
53.7%, 37.0%, and 9.3% of patients,
3
 MAYO CLINIC PROCEEDINGS

perceived and estimated risk of bleeding

TABLE 1. Baseline Characteristics of the 227 Study Patients
while receiving OAC (r¼0.16; P¼.02). The
Characteristic Value estimated annual bleeding risk based on
Age (y), mean
SD 72.2
10.2 the HAS-BLED score was 1% to 3%, 4% to
Male sex (No. [%]) 125 (55.1) 6%, 7% to 10%, and greater than 10%, in
Atrial fibrillation provider (No. [%]) 54.0%, 31.6%, 13.5%, and 0.9% of patients,
Primary care physician 13 (5.7) respectively, and the risk perceived by pa-
Cardiologist (electrophysiologist) 91 (40.1) tients was 1% to 3%, 4% to 6%, 7% to 10%,
Cardiologist (nonelectrophysiologist) 123 (54.2)
and greater than 10% in 61 (28.4%), 25
Years since atrial fibrillation diagnosis (No. [%])
(11.6%), 14 (6.5%), and 115 (53.5%),
<1 58 (25.6)
respectively (Table 2, Figures 1 and 2).
1-5 63 (27.8)
>5 106 (46.7)
Effectiveness of OAC in Reducing the Risk of
Congestive heart failure (No. [%]) 115 (50.7)
Stroke. Most patients believed that OAC is
Hypertension (No. [%]) 201 (88.5)
very effective in reducing stroke risk. A total
Diabetes (No. [%]) 79 (34.8)
of 102 patients (44.9%) believed that OAC
Vascular disease (No. [%]) 109 (48.0)
would reduce their annual risk of stroke by
History of stroke/TIA (No. [%]) 52 (22.9)
50%, and 59 (30.0%) and 43 (19.0%)
Chronic renal insufficiency (No. [%]) 16 (7.0)
thought that OAC leads to 70% and 90%,
Impaired liver function (No. [%]) 5 (2.2) respectively, odds of stroke reduction
Labile INR (No. [%]) 25 (11.0) (Table 2).
Antiplatelet use (No. [%]) 136 (59.9) A total of 173 patients (76.2%) were tak-
Alcohol consumption (No. [%]) 21 (9.3) ing OACs. Among the 54 patients who were
History of bleeding (No. [%]) 92 (40.5) not taking OACs, fear of bleeding was the
CHA2DS2VASc score (mean
SD) 4.3
1.6 predominant reason (n¼37; 68.5%). Patients
CHA2DS2VASc score (No. [%]) who were taking OACs did so to reduce their
1-2 33 (14.5) risk of stroke (n¼131; 75.7%), due to physi-
3-4 89 (39.2) cian recommendations (n¼21; 12.0%), and
5-6 84 (37.0)
for uncertain reasons (n¼15; 8.7%). Approx-
7 21 (9.3)
imately half of the patients (n¼118) were
HAS-BLED score (mean
SD) 2.3
1.2
not aware or did not know of any other pre-
HAS-BLED score (No. [%])
vention option besides blood thinners
1-2 121 (53.3)
3-4 98 (43.2) (Table 2).
5 8 (3.5)
Highest level of education (No. [%]) Predictors of Inaccurate Risk Assessment
No formal education/no high school diploma 62 (27.3) Of the 8 clinical and demographic variables
High school or equivalent 96 (42.3) included in the logistic regression analysis,
Some college, associate degree or equivalent 35 (15.4) none were predictive of false perception
Bachelor’s degree 20 (8.8)
or severe false perception of stroke risk
Master’s degree or higher degree 14 (6.2)
in the patient cohort (Supplemental
INR ¼ international normalized ratio; TIA ¼ transient ischemic attack.
Table 3, available online at http://www.
mayoclinicproceedings.org). However, his-
respectively, and the risk of stroke perceived tory of bleeding was a strong independent
by patients was 1% to 5%, 6% to 10%, 11% predictor of false perception (odds ratio,
to 20%, 21% to 50%, and greater than 50% 3.26; 95% CI, 1.27-8.37; P¼.01) or severe
in 15.9%, 14.5%, 16.7%, 32.6%, and 20.3% false perception (odd ratio, 5.07; 95% CI,
of patients, respectively (Table 2, Figures 1 2.64-9.75; P<.001) of bleeding risk. In addi-
and 2). tion, duration of AF greater than 1 year, fe-
male sex, and HAS-BLED score greater than
Annual Bleeding Risk With OAC. There was 3 independently predicted severe false
also a negligible correlation between patient perception of bleeding risk (Supplemental
n n
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RISK PERCEPTION IN PATIENTS WITH AF

Tables 4 and 5, available online at http://

TABLE 2. Results of the Study Survey
www.mayoclinicproceedings.org).
(1) Does AF increase your risk of having a stroke? (n¼287)
Yes 227 (79.1)
Validation of the Survey Instrument
No/I do not know 60 (20.9)
The C-statistic, which describes the discrim-
(2) What do you think your yearly risk of having a stroke is? (n¼227)
ination of a model, was 0.909 (95% CI,
1%-5% 36 (15.9)
0.855-0.963) in the derivation set. We found 6%-10% 33 (14.5)
similar discrimination in the bootstrapped 11%-20% 38 (16.7)
cohort (C-statistic, 0.909; 95% CI, 0.855- 21%-50% 74 (32.6)
0.963). The C-statistic in the validation >50% 46 (20.3)
cohort was 0.89 (95% CI, 0.823-0.958) (3) How much do blood thinners reduce your annual risk of stroke? (n¼227)
(Figure 3). 10% 9 (4.0)
30% 14 (6.2)
50% 102 (44.9)
DISCUSSION
70% 59 (26.0)
The findings of this cross-sectional study
90% 43 (18.9)
demonstrate a major knowledge gap in pa-
(4) What do you think is the yearly risk of you of suffering a major bleeding
tients with AF regarding their estimated with event blood thinners? (n¼215)a
risk of stroke and the risks and benefits of 1%-3% 61 (28.4)
OAC for stroke prevention. 4%-6% 25 (11.6)
Oral anticoagulation with warfarin or 7%-10% 14 (6.5)
nonevitamin K OACs is the mainstay stroke >10% 115 (53.5)
prevention strategy in patients with AF, with (5) Are you currently taking a blood thinner? (n¼227)
safety and efficacy supported by a large body Yes 173 (76.2)
No 54 (23.8)
of evidence.5,6 However, for an individual
patient, lifelong OAC is a substantial under- (6) A- Why are you taking blood thinners? (n¼173)
My doctor recommended it 21 (12.0)
taking, the success of which relies on solid
To reduce the risk of having a stroke 131 (75.7)
understanding of the indication, risk- To prolong life 2 (1.2)
benefit ratio, cost, and alternatives.7,8 How- To reduce the risk of having a heart attack 4 (2.4)
ever, the available data, albeit scarce, suggest I do not know/I am not sure 15 (8.7)
a limited knowledge of the risk of stroke and B- What is the reason for not taking a blood thinner? (n¼54)
the risks and benefits of various stroke pre- Not offered to me 3 (5.6)
vention modalities in patients with AF.4,9-11 Not convinced it is necessary 2 (3.7)
Too expensive 2 (3.7)
Of 1004 patients participating in the Survey
Worried about side effects 37 (68.5)
of Patient Knowledge and Personal Priorities Worried about lifestyle changes 6 (11.1)
for Treatment study, only 50% and 8% re- I do not know/I am not sure 4 (7.4)
ported high understanding of the role of (7) What are other options for stroke prevention other than blood
nonevitamin K OAC and left atrial thinners? (n¼227)
appendage occlusion, respectively, in stroke No treatment/no other options 62 (27.3)
prevention.9 Knowledge of stroke risk and Aspirin/Plavix or both 13 (5.7)
benefit of OAC was limited even in patients Surgery 15 (6.6)
with previous strokes in another study. Watchman device/left atrial appendage occlusion 81 (35.7)
I do not know 56 (24.7)
To our knowledge, only 1 study has pre-
a
Twelve patients declined to estimate their bleeding risk.
viously investigated the discrepancy between
subjective perceived and objective estimated
risks of stroke and bleeding in patients with
AF. Zweiker et al4 surveyed 91 patients with
AF in Austria and found that only approxi- were not able to correctly estimate their risk
mately one-third were able to correctly esti- of stroke. However, most patients in this
mate their risk of stroke, with most (57%) study overestimated their stroke risk. The
underestimating that risk. In the present differences in the findings could be related
cohort, we similarly found that most patients to the studied populations or the survey
Mayo Clin Proc. n XXX 2019;nn(n):1-9 n https://doi.org/10.1016/j.mayocp.2018.08.043 5
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100
80
Patients (%)
Patients (%)
60
40
20
0 0
Actual Perceived
Stroke risk based on CHA2DS2-VASc score
1%-5% 6%-10% 11%-20% 21%-50% >50%
A B
FIGURE 1. Differences in perceived vs objectively estimated annual risks of stroke (A) and bleeding (B) in patients with atrial
fibrillation.
methods: in the study by Zweiker et al, pa-
tients with newly diagnosed AF were asked
to estimate their risk of stroke and bleeding
as low, intermediate, high, or very high; in
the present study, we surveyed patients
with chronic AF and used numeric risk esti-
mate scales. We used this method not only
to obtain a more quantitative assessment of
patient perception but also to allow the in-
clusion of perceived risk values beyond the
traditional values calculated by the various
risk scores. The present finding that more
than 50% of patients perceived their annual
stroke risk to be greater than 20% is con-
cerning and suggests that most patients (at
least in this survey) may have made an unin-
formed decision about stroke prevention
based on an unrealistically exaggerated
perception of their risks.
The decision to accept or decline preven-
tive measures for a potential event (eg,
ischemic stroke in the context of AF) ulti-
mately belongs to the patient. The physi-
cian’s role is to integrate the patient’s risk
profile with the clinical data to provide an
evidence-based recommendation to facilitate
a well-informed decision by that patient.
However, there seems to be a significant
gap between physician and patient interpre-
tation of risks, which may greatly affect
6 Mayo Clin Proc.
MAYO CLINIC PROCEEDINGS
100
80
60
40
20
Actual Perceived
Bleeding risk based on HAS-BLED score
1%-3% 4%-6% 7%-10% >10%
patients’ decisions and potentially their
compliance with the recommended preven-
tion strategy. Patients seem to accept certain
measures based on a false perception of a
substantial annual risk of stroke if these
measures are not taken. Would patients
accept lifelong OAC if they become aware
that they have a greatly exaggerated percep-
tion of the risk? For example, patients with
AF and a CHA2DS2-VASc score of 3 have
an estimated annual stroke risk of 3.2%,
which is an indication for lifelong OAC in
major guidelines. Would these patients
accept long-term OAC if they correctly iden-
tified their annual stroke risk without OAC
as 3.2%? Similarly, most patients in this
study overestimated their bleeding risk while
receiving OAC. This excess perceived
bleeding risk was the main reason for
declining OAC in the 21% of patients who
are not taking OAC despite their physician’s
recommendation. Would those patients have
accepted OAC if they had a more accurate
perception of the associated bleeding risk?
Another intriguing finding in the present
study is that the magnitude of discrepancy
between perceived and estimated risks was
most profound regarding estimates that are
traditionally presented in absolute values
(eg, stroke risk) compared with those
n n
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RISK PERCEPTION IN PATIENTS WITH AF
Estimated stroke risk (%)
11-20
6-10
1-5
1-5
A Perceived stroke risk (%)
>10
Estimated bleeding risk (%)
7-10
4-6
1-3
1-3
B Perceived bleeding risk (%)
FIGURE 2. Distribution of perceived and objectively estimated annual risks of stroke (A) and bleeding (B)
in individual patients with atrial fibrillation.
presented in relative values (eg, benefit of
OAC). These provocative data imply that
the current methods of sharing risk and
risk reduction values with patients might
need to be revisited. For example, a high-
risk CHA2DS2-VASc score of 5 has an esti-
mated annual stroke risk of 6.7%. Compared
with aspirin, OAC with warfarin in this pa-
tient would reduce the risk of stroke to
3.7%, a substantial risk reduction when pre-
sented to the patient in relative terms (45%)
but less remarkable when presented in abso-
lute terms (3%). Whether the way in which
the benefits of OAC are presented (relative
vs absolute risk reduction) will affect pa-
tients’ attitudes toward management of their
stroke risk remains to be assessed in further
studies.
Mayo Clin Proc. n XXX 2019;nn(n):1-9
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P=.32 r=0.066
6-10 11-20 21-50 >50
P=.02 r=0.16
4-6 7-10 >10
Similar to what has been reported in
other studies, patients also overestimated
their risk of bleeding.11 Interestingly, despite
that and despite the high incidence of previ-
ous bleeding in this cohort of patients
(40%), only 26% of patients were not
receiving OAC. This may be partially
explained by the finding that most patients
in this study (n¼214; 94.3%) received AF-
related care from a cardiology specialist. In
the TREAT-AF (Retrospective Evaluation
and Assessment of Therapies in AF) study,
cardiology care was associated with
improved outcomes in patients with newly
diagnosed AF, mostly mediated by the early
prescription of OAC therapy.12
This study has several limitations
inherent to cross-sectional cohort studies.
n https://doi.org/10.1016/j.mayocp.2018.08.043 7

1.0
0.8
0.6
Sensitivity
0.4
0.2
0.0
0.0 0.2 0.4 0.6 0.8 1.0
1-Specificity
FIGURE 3. Validation of the survey instrument in the validation set cohort.
(1) We enrolled consecutive unselected pa-
tients from highly specialized care locations.
Hence, this cohort might not be representa-
tive of a wider range of AF cohorts cared
for in more diverse settings. (2) The results
of this study can, in part, be site specific
and, hence, may not be generalizable. How-
ever, several single-center and multicenter
studies have found similar knowledge gaps
in patients undergoing various preventive
and therapeutic interventions, suggesting
that the knowledge gap in patient perception
of the risks and benefits of certain interven-
tions is more global than local.13-16 (3) There
are no validated published surveys to assess
patient perception of stroke risk and preven-
tion. Although we developed this survey in
collaboration with a behavioral scientist, we
cannot ascertain the absence of bias/con-
founding variables introduced by this survey
method. (4) No variables have been identi-
fied as independent predictors of false
perception of stroke risk in the univariate
regression analysis, but this might have
been hampered by the modest sample size
of the cohort. Further studies are needed to
further confirm the present study’s findings
and understand the underlying reasons for
false perception in these patients. (5) Pa-
tients in this study represented a full
n n
8 Mayo Clin Proc.
MAYO CLINIC PROCEEDINGS
spectrum of patients with AF (paroxysmal
vs nonparoxysmal, educated vs less
educated, previous bleeding vs not, high
risk vs low risk). Hence, the results of this
study should be interpreted in that context;
perhaps patients with longer-standing AF
or those with previous bleeding have a
distinctly different perception of risk than
those with newly diagnosed AF with an un-
complicated history.
CONCLUSION
In contemporary practice, perceived risks of
stroke and bleeding are markedly overesti-
mated in most patients with AF. Further
studies are needed to identify effective strate-
gies to address this profound gap between
patient perceptions and objectively esti-
mated risks.
SUPPLEMENTAL ONLINE MATERIAL
Supplemental material can be found online
at http://www.mayoclinicproceedings.org.
Supplemental material attached to journal
articles has not been edited, and the authors
take responsibility for the accuracy of all
data.
Abbreviations: AF = atrial fibrillation; INR = international
normalized ratio; OAC = oral anticoagulation; TIA = transient
ischemic attack
Potential Competing Interests: The authors report no
competing interests.
Correspondence: Address to Mohamad Alkhouli, MD,
West Virginia University School of Medicine, 1 Medical
Center Dr, Morgantown, WV, 26505-8059 (Mohamad.
Alkhouli@wvumedicine.org).
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