Underuse of Oral Anticoagulants for Nonvalvular Atrial Fibrillation: Past, Present, and Future

Wehbe, Ramsey M.; Yadlapati, Ajay

doi:10.14503/thij-16-5785

Cited by 12 publications

(7 citation statements)

References 49 publications

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“…This is in contrast to the results of national and international surveys among office-based physicians disclosing a sustained underuse of oral anticoagulation in those patients [9][10][11][12]. On the one hand, oral anticoagulation is mainly restrained to avoid major bleeding, which is an immanent side effect of any anticoagulant and considered an iatrogenic complication [13]. Ischemic stroke in patients not receiving anticoagulation, on the other hand, is deemed somewhat fateful.…”

Section: Introductionmentioning

confidence: 84%

Modification of In-Hospital Recommendation and Prescription of Anticoagulants for Secondary Prevention of Stroke after Launch of Direct Oral Anticoagulants and Change of National Guidelines

Gronemann¹,

Hause²,

Assmann³

et al. 2020

Cerebrovasc Dis

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Introduction: Approximately 1 out of 4 stroke patients suffers ischemic stroke secondary to atrial fibrillation (AF). Although indicated, withholding of anticoagulants for secondary prevention is a widespread phenomenon. Objective: We examined the longitudinal change of recommendation and prescription of secondary preventive anticoagulation in AF patients in an acute stroke center setting focusing on the impact of the introduction of direct oral anticoagulants (DOACs) and the change of national stroke prevention guidelines. Methods: Consecutive patients admitted with an acute cerebrovascular ischemic event underwent regular diagnostic work-up. Pseudonymized clinical data were entered into the institution's stroke registry. In those patients with AF, discharge letters were collected and evaluated for temporal trends and affecting factors of recommended and prescribed antithrombotic secondary medication at the time of discharge from hospital. Results: Of 7,175 patients admitted between January 2009 and December 2018, 1,812 (25.3%) suffered stroke caused by AF. Frequency of patients with recommended anticoagulation increased within the observation period from 66.7 to 95.8% (per year; adjusted odds ratio [OR], 1.309; confidence interval [CI], 1.153-1.486). Independently from this time trend, DOAC approval (adjusted OR, 4.026; CI 1.962-8.265) and guideline change (adjusted OR, 2.184; CI, 1.006-4.743) were associated with an increasing frequency of recommendation for anticoagulation. The rate of patients already receiving recommended anticoagulation for secondary prevention at discharge increased from 42.1 to 62.5%. Introduction of DOACs was not associated with this trend, and guideline change was even associated with decreasing frequency of anticoagulated patients at hospital discharge (adjusted OR, 0.641; CI, 0.414-0.991). Fear of early intracerebral bleeding was the most common reason for withholding anticoagulation (37%) at hospital dis-Christian Gronemann and Stephan Hause contributed equally to this article.

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Section: Introductionmentioning

confidence: 84%

Modification of In-Hospital Recommendation and Prescription of Anticoagulants for Secondary Prevention of Stroke after Launch of Direct Oral Anticoagulants and Change of National Guidelines

Gronemann¹,

Hause²,

Assmann³

et al. 2020

Cerebrovasc Dis

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“…Many factors play a crucial role in the underuse of OACs, including patient characteristics (i.e., older age or female sex), comorbidities (i.e., hepatic or renal disease), non-compliance or low balance between therapeutic efficacy and safety risks associated with drugs [26–28]. In addition, fear of treatment and lack of access to the healthcare system may contribute to underuse [27].…”

Section: Discussionmentioning

confidence: 99%

Antithrombotic Treatment Patterns in Patients With Atrial Fibrillation in Italy pre- and post-DOACs: the Repair Study

Esposti¹,

Brière

Bowrin

et al. 2019

Future Cardiol.

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Aim: To evaluate antithrombotic treatment patterns in patients in Italy with nonvalvular atrial fibrillation (NVAF) before and after direct oral anticoagulants (DOACs) were approved. Methods: This analysis included patients with a discharge diagnosis of NVAF in 2010 and 2014, which constituted the pre- and post-DOACs populations, respectively. Results: Approximately 90% of patients were eligible for oral anticoagulant (OAC) therapy. Overall use of OACs increased from 38% in 2010 to 45% in 2014; use of antiplatelet therapy decreased from 36 to 25%. Approximately 14% of eligible patients remained untreated. Conclusion: Although an improvement in OAC prescription was observed post-DOACs launch, treatment patterns in Italy suggest that a proportion of patients with NVAF are still undertreated or do not receive appropriate therapy.

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“…CHA 2 DS 2 -VASc score of 2 or higher), with treatment choice based on a patient's risk profile, clinical condition, values, and preferences 3,4 . However, studies have found that real-world AC treatment practices are often suboptimal with OAC treatment underused among at-risk AF patients [13][14][15][16][17] . An American College of Cardiology National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence study of 429,417 patients who had AF found that less than one-half of those with a high risk of stroke were prescribed OAC therapy in the outpatient cardiology practice setting 15 .…”

Section: Introductionmentioning

confidence: 99%

Utilization of anticoagulants and predictors of treatment among hospitalized patients with atrial fibrillation in the USA

Deitelzweig

Dhamane

Fusco

et al. 2020

Journal of Medical Economics

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Objective: To evaluate utilization of anticoagulants (ACs) and the predictors of treatment of patients with a diagnosis of atrial fibrillation (AF) during a hospital stay in the USA. Methods: Patients (!18 years of age) who had a primary or secondary discharge diagnosis code of AF during a hospitalization (without a diagnosis of venous thromboembolism) were identified from the Premier Hospital database (1 January 2016-30 September 2017). AC treatments were examined during hospitalizations to assign AF patients into 3 study cohorts: those who received an oral AC (OAC), those who received parenteral AC only, and those who did not receive AC therapy. Multivariable logistic regression analyses were carried out to evaluate potential predictors of receiving parenteral AC only vs. OAC therapy, no AC therapy vs. OAC therapy, as well as the specific OAC drug choices. Results: Of the patients hospitalized with an AF diagnosis (n ¼ 482,729; mean age: 74.7 years; 46.8% female; 82.9% White; 79.4% with Medicare), 42.6% received OAC therapy (most commonly, warfarin or apixaban), 35.3% parenteral AC only, and 22.2% no AC therapy. A key predictor of not receiving OAC therapy was having an AF diagnosis in the second position (applicable to 87.4% of study population). Greater comorbidity level and prior baseline bleeding were strong predictors of receiving parenteral AC only or not receiving any AC therapy vs. receiving OAC therapy. Predictors of receiving warfarin vs. apixaban included higher stroke risk and prior baseline bleeding. Limitations: OAC utilization may have been underestimated since outpatient OAC utilization was not included in the analysis. Conclusions: A substantial portion of hospitalized AF patients did not receive any AC therapy, particularly those patients with an AF diagnosis in the second position on hospital records. The predictors of inpatient AC treatment that were identified may be helpful in the clinical decision-making process for patients who are hospitalized with AF.

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Underuse of Oral Anticoagulants for Nonvalvular Atrial Fibrillation: Past, Present, and Future

Cited by 12 publications

References 49 publications

Modification of In-Hospital Recommendation and Prescription of Anticoagulants for Secondary Prevention of Stroke after Launch of Direct Oral Anticoagulants and Change of National Guidelines

Modification of In-Hospital Recommendation and Prescription of Anticoagulants for Secondary Prevention of Stroke after Launch of Direct Oral Anticoagulants and Change of National Guidelines

Antithrombotic Treatment Patterns in Patients With Atrial Fibrillation in Italy pre- and post-DOACs: the Repair Study

Utilization of anticoagulants and predictors of treatment among hospitalized patients with atrial fibrillation in the USA

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