77 Preventing stroke in patients with atrial fibrillation and intracerebral haemorrhage: a qualitative study of physicians’ decision-making

<h3>Introduction</h3> Initiating long-term oral anticoagulation (OAC) therapy in patients with atrial fibrillation (AF) who have sustained an intracerebral haemorrhage (ICH) has clinical equipoise due to the lack of clinical trial evidence. Understanding how physicians make decisions about stroke prevention in these patients will support and improve current decision-making practice and inform future guidelines. <h3>Aim</h3> To explore physicians’ decision-making around prescription of long-term OAC for stroke prevention in patients with AF following an ICH. <h3>Methods</h3> Qualitative sub-study of the PREvention of STroke in Intracerebral haemorrhaGE survivors with Atrial Fibrillation (PRESTIGE-AF) trial [NCT NCT03996772]. Semi-structured interviews with data analysed using Framework analysis. <h3>Results</h3> Twenty physicians across five European countries (Spain, France, Germany, Austria, UK) participated. The umbrella theme ‘Managing uncertainty’, addressed the process of making high-risk clinical decisions in the context of little available robust trial evidence for best practice. Three sub-themes were identified under the umbrella theme: (1) ‘Computing the Risks’, captured the challenge of balancing the risks of ischaemic stroke with the risk of recurrent ICH; (2) ‘Patient Factors’ highlighted the influence that patients’ health beliefs, previous experience of stroke, and willingness to engage with OAC had on physicians’ decisions; and (3) ‘Making a Decision’ explored the process of reaching a final decision regarding initiation of OAC therapy or not (Figure). <h3>Conclusion</h3> Key factors that affected decision-making were patient comorbidities, functional status, and physician-perceived patient willingness to engage with OAC. The sense of clinical equipoise led to physicians relying as much on their personal experience and on joint decision-making with fellow physicians as on available clinical evidence. Shared decision-making between the physician and the patient was believed to be beneficial but physicians believed that the ultimate responsibility to decide on stroke prevention lay with them. Future practice should support physicians in communicating clinical uncertainty to patients and encourage patients and physicians to work together to understand individual patients’ needs. <h3>Conflict of Interest</h3> None