The burden of undertreatment and non-treatment among patients with non-valvular atrial fibrillation and elevated stroke risk: a systematic review

Abstract

Objective: Global treatment guidelines recommend treatment with oral anticoagulants (OACs) for patients with non-valvular atrial fibrillation (NVAF) and an elevated stroke risk. However, not all patients with NVAF and an elevated stroke risk receive guideline-recommended therapy. A literature review and synthesis of observational studies were undertaken to identify the body of evidence on untreated and undertreated NVAF and the association with clinical and economic outcomes. Methods: An extensive search (1/2010-4/2020) of MEDLINE, the Cochrane Library, conference proceedings, and health technology assessments (HTAs) was conducted. Studies must have evaluated rates of nontreatment or undertreatment in NVAF. Nontreatment was defined as absence of OACs (but with possible antiplatelet treatment), while undertreatment was defined as treatment with only antiplatelet agents. Results: Sixteen studies met our inclusion criteria. Rates of nontreatment for patients with elevated stroke risk ranged from 2.0-51.1%, while rates of undertreatment ranged from 10.0-45.1%. The clinical benefits of anticoagulation were reported in the evaluated studies with reductions in stroke and mortality outcomes observed among patients treated with anticoagulants compared to untreated or undertreated patients. Adverse events associated with all bleeding types (i.e. hemorrhagic stroke, major bleeding or gastrointestinal hemorrhaging) were found to be higher for warfarin patients compared to untreated patients in real-world practice. Healthcare resource utilization was found to be lower among patients highly-adherent to warfarin compared to untreated patients. Conclusions: Rates of nontreatment and undertreatment among NVAF patients remain high and are associated with preventable cardiovascular events and death. Strategies to increase rates of treatment may improve clinical outcomes.

Clinical Complexity Domains, Anticoagulation, and Outcomes in Patients with Atrial Fibrillation: A Report from the GLORIA-AF Registry Phase II and III

“…However, OAC undertreatment remains a concern in AF patients, 8 9 being also associated with worse outcomes, 10 especially in high-risk patients. Indeed, with the progressive aging of the AF population, a significant proportion of patients are burdened by concomitant comorbidities and conditions that increase both thromboembolic and bleeding risks, entailing the so-called “clinical complexity” that influences treatment choices and poses significant challenges in the management of AF.…”

“…Since their introduction, the non-vitamin K antagonist OACs (NOACs; also referred to as direct OACs) represented a safer and effective alternative to vitamin K antagonist (VKA) for stroke prevention in AF patients, 3 and this was reflected by the increasing uptake of NOACs in clinical practice. [4][5][6][7] However, OAC undertreatment remains a concern in AF patients, 8,9 being also associated with worse outcomes, 10 especially in high-risk patients. Indeed, with the progressive aging of the AF population, a significant proportion of patients are burdened by concomitant comorbidities and conditions that increase both thromboembolic and bleeding risks, entailing the so-called "clinical complexity" that influences treatment choices and poses significant challenges in the management of AF.…”

Time trends in antithrombotic therapy prescription patterns: Real-world monocentric study in hospitalized patients with atrial fibrillation

“…Actually, DOAC adoption trends are quite variable, with slow integration into clinical practice reported in most countries[ 98 ]. A systematic literature review indicates that suboptimal OACs use is a persisting challenge, despite the availability of DOACs[ 100 ]. After the launch of the first DOAC in 2011, the proportion of DOACs as OAC increased from 3% in 2012 to 42% in 2016 ( P < 0.0001 for the trend)[ 16 ].…”

“…These data are consistent with other studies, showing that a total varying from 21.9% to 30.2% did not receive any prophylactic antithrombotic therapy[ 46 , 60 , 70 , 75 , 90 ] with substantial variations across countries. A recent meta-analysis reviewed a total of 11,231 publications, demonstrating in patients with high stroke risk a rate of non-treatment of 23.3% (7.9%-51.1%)[ 100 ]. Undertreatment is frequent in female and older patients, notwithstanding their great stroke risk[ 36 , 87 , 93 , 105 ].…”

Development of a Care Pathway for Atrial Fibrillation Patients in the Emergency Department

“…22 Although anticoagulation is strongly recommended in all major AF guidelines, [3][4][5] physician practices vary widely, and some studies suggest the rate of nontreatment in the United States, both for hospitalized or ambulatory patients, may be as high as 50% in patients with elevated stroke risk. [23][24][25] It is estimated that 50,000 preventable strokes per year occur in the United States related to suboptimal anticoagulation care for AF. 26 A recent Canadian study showed that initiation of oral anticoagulation in the ED is associated with higher long-term use than when prescription is deferred to outpatient care following discharge.…”