Oral anticoagulant underutilization among elderly patients with atrial fibrillation: insights from the United States Medicare database

Munir, Muhammad Bilal; Hlavacek, Patrick; Keshishian, Allison; Guo, Jennifer; Mallampati, Rajesh; Ferri, Mauricio; Russ, Cristina; Emir, Birol; Cato, Matthew; Yüce, Hüseyin; Hsu, Jonathan C.

doi:10.1007/s10840-022-01274-1

Cited by 9 publications

(5 citation statements)

References 28 publications

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“…Female patients with a low risk of stroke were 30% less likely to receive an OAC than males. Several other reports have shown females were less likely to be prescribed an OAC [36][37][38][39], regardless of stroke risk, despite tending to have an increased risk of stroke compared to males [37]. Similarly, patients with better socioeconomic status had a 25-35% lower likelihood of receiving an OAC.…”

Section: Discussionmentioning

confidence: 87%

Oral Anticoagulant Use in Patients with Atrial Fibrillation at Low Risk of Stroke and Associated Bleeding Complications

Kefale,

Bezabhe,

Peterson

2023

JCM

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Background: The use of oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and low stroke risk might cause more harm than benefit. Little attention has been given to address its prevalence and associated consequences. This study aimed to investigate the prescription rate of OACs, identify associated factors, and describe incident bleeding events in low-risk patients. Methods: We included patients with a new diagnosis of AF between 1 January 2011 and 31 December 2018 having a low risk of stroke (CHA2DS2-VASc score of 0 for males and 1 for females) from Australian general practice data (MedicineInsight). Patients were classified as OAC users if there was a recorded prescription of an OAC within 60 days of AF diagnosis, and factors associated with the prescription of an OAC were assessed using logistic regression. Recorded incident bleeding events were identified within 6 months after AF diagnosis or after OAC initiation for OAC non-users and users, respectively. The risk of bleeding was compared between the two groups by adjusting their baseline differences using propensity score matching. Results: The study included 2810 low-risk patients (62.3% male) with a mean age of 49.3 ± 10.8 years. Of the total, 705 (25.1%) patients had a record of OAC prescription within 60 days of diagnosis of AF. Older age (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.03–1.04) and diagnosis periods (2015–2016 [OR 1.46; 95% CI 1.10–1.94] and 2017–2018 [OR 1.65; 95% CI 1.17–2.23] vs. 2011–2012) were associated with higher odds of OAC initiation. Female sex (OR 0.71; 95% CI 0.59–0.85), higher bleeding risk (ORBIT score; OR 0.80; 95% CI 0.68–0.94), and higher socioeconomic index for areas (SEIFA) quintiles (SEIFA quintiles; 2 [OR 0.65; 95% CI 0.48–0.88], 3 [OR 0.74; 95% CI 0.56–0.98], 4 [OR 0.70; 95% CI 0.52–0.94], 5 [OR 0.69; 95% CI 0.52–0.91] compared with quintile 1) were associated with lower odds of OAC prescription. A total of 52 (in 1.8% of patients) incident bleeds were identified, with 18 (2.6%) among OAC users. The rate of bleeding was not significantly different between users and non-users after matching. However, within OAC users, commencement of OAC was associated with an increased risk of bleeding compared to the period before OAC initiation (p = 0.006). Conclusions: One in four patients at low risk of stroke received an OAC within 60 days of AF diagnosis. Older age and the period following the widespread availability of direct-acting OACs were associated with an increased likelihood of OAC prescription. Positively, using OACs was not associated with an increased rate of bleeding compared to non-users.

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Section: Discussionmentioning

confidence: 87%

Oral Anticoagulant Use in Patients with Atrial Fibrillation at Low Risk of Stroke and Associated Bleeding Complications

Kefale,

Bezabhe,

Peterson

2023

JCM

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“…Extensive retrospective studies and meta-analyses of patients with AF showed that despite being considered high-risk of stroke or thromboembolism, a large group did not receive anticoagulants, even those without contraindications [ 1 , 12 , 13 ]. The United States Medicare database analysis revealed that 51.3% of patients diagnosed with AF were not prescribed an OAC during the mean follow-up of 2.4 years [ 23 ]. In the Spanish study, which focused on patients with non-valvular AF and moderate-to-high risk of stroke, 20% of analysed individuals did not receive OAC even if there were no clear contraindications to OACs [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

Anticoagulant Treatment in Patients with AF and Very High Thromboembolic Risk in the Era before and after the Introduction of NOAC: Observation at a Polish Reference Centre

Bielecka

Gorczyca

Ciba-Stemplewska

et al. 2023

IJERPH

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Atrial fibrillation (AF) is associated with an increased risk of stroke. Therefore, patients with AF require appropriate management and anticoagulant therapy. To balance therapy risks and benefits, oral anticoagulants (OAC) treatment should be ‘tailored’ in patients at a high risk of stroke and bleeding. However, some studies have demonstrated that certain groups of patients do not receive anticoagulants despite the high risk of stroke or thromboembolism. The study aimed to analyse therapeutic methods of stroke prevention in very high-risk patients (CHA2DS2-VASc score of ≥5 in men and ≥6 in women), identify factors predisposing against the use of OACs and assess the administration of anticoagulants before the introduction of non-vitamin K antagonist OAC (NOAC) in 2004–2011 and beyond (years 2012–2019). The analysis covered 2441 patients with AF at a very high thromboembolic risk who were hospitalised in a reference cardiological centre from 2004 to 2019. Data concerning patients’ sex, age, comorbidities, type of AF, renal and echocardiographic parameters, reasons for hospitalisation and applied treatment were collected from medical records. HAS-BLED, CHADS2, and CHA2DS2-VASc scores were calculated for all patients. The treatment with oral anticoagulants was compared in the entire population over 2004–2011 and 2012–2019. In this study, a fifth of patients were not treated with OAC. Most patients hospitalised in the years 2012–2019 were treated with OAC. The predictors of not using OAC turned out to be: age of >74 years, heart failure, cancer, paroxysmal AF, and acute coronary syndrome (ACS) or elective coronary angiography/percutaneous coronary intervention (PCI) as a reason for hospitalisation. The introduction of NOAC was associated with a decline in the use of VKA (from 62% to 19.1%) and APT (from 29.1% to 1.3%). This study outlines reasons to initiate OAC treatment in very high-risk patients in clinical practice.

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“… 322 Recent analyses coming from the USA, focusing on patients ≥65 years old with high thrombo-embolic risk, indeed revealed the fact that despite a significant OAC uptake over time, there is still a substantial under prescription, particularly in oldest-old and in patients with chronic conditions. 323 , 324 …”

Section: Special Circumstances With Regards To Stroke Prevention In A...mentioning

confidence: 99%

Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal

Lip,

Proietti,

Potpara

et al. 2023

Europace

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Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient’s psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.

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Oral anticoagulant underutilization among elderly patients with atrial fibrillation: insights from the United States Medicare database

Cited by 9 publications

References 28 publications

Oral Anticoagulant Use in Patients with Atrial Fibrillation at Low Risk of Stroke and Associated Bleeding Complications

Oral Anticoagulant Use in Patients with Atrial Fibrillation at Low Risk of Stroke and Associated Bleeding Complications

Anticoagulant Treatment in Patients with AF and Very High Thromboembolic Risk in the Era before and after the Introduction of NOAC: Observation at a Polish Reference Centre

Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal

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