Table 4.

Barriers to implementation of ESC 2012 guidelines

Barrier
Practical
Under-diagnosis of AF because of lack of access to diagnostic tools for AF (e.g. Holter monitoring) Not screening using the most efficient technique, e.g. loop monitoring for paroxysmal AF Underestimation of thromboembolic risk Applicability of ESC guidelines to non-European populations
Educational
Lack of widespread awareness of ESC 2012 Guidelines (coupled with use of other/pre-existing guidelines) Delay in updates of local guidelines to reflect major environmental changes for practice Fear of major bleeding/lack of validated scores to evaluate bleeding risk (HAS-BLED was developed based on VKA studies) Lack of technical expertise Development and availability of multiple NOACs in a relatively short timeframe has led to confusion about protocols for use and the specific properties of each drug –  Exacerbated by manufacturers providing different information about the drugs in the prescribing information vs. the summary of product characteristics and using different marketing approaches –  Influenced by media reports, e.g. reports of severe bleeding when dabigatran was first introduced
Access
Budget restrictions and/or reimbursement issues with NOACs Limitations/restrictions on patients considered eligible for NOACs that are inconsistent with broader guideline recommendations Limitations of prescriber eligibility Administrative hurdles associated with prescription of NOACs (e.g. completion of paperwork and justification of the clinical decision)

AF, atrial fibrillation; HAS-BLED, Hypertension, Abnormal liver/renal function, Stroke history, Bleeding predisposition, Labile INR, Elderly (age >65 years), Drug/alcohol use; NOAC, non-vitamin K antagonist oral anticoagulant; VKA, vitamin K antagonist; INR, international normalized ratio.