Use of oral anticoagulation therapy in the first 3 months after the diagnosis of atrial fibrillation in Israel: A population‐based study

Abstract

Introduction: Oral anticoagulation (OAC) therapy reduces the risk of ischemic stroke in patients with atrial fibrillation (AF) while increasing the risk of bleeding.Recently, non-vitamin K antagonist oral anticoagulants (NOACs) have become available with lower rates of intracranial bleeding, and some of them have presented a reduced risk of major bleeding. The purpose of this study is to evaluate the change in purchasing patterns of OACs (both warfarin and NOACs) over time in patients with AF according to stroke and bleeding risk, in the first 3 months after diagnosis. Methods and Results:We conducted a historical cohort study using the Clalit Health Services electronic medical records database. The study population included all members aged ≥21 years, with a new diagnosis of nonvalvular AF between 2008 and 2015. A total of 58 385 cases were identified. The mean age was 73.1 (±14.1) years, and 52.3% of the patients were women. The median CHA 2 DS 2 -VASc score was 4 (interquartile range, 3-5). OACs were purchased by 19 705 patients (33.8%) within the first 3 months of first diagnosis of AF, with patients at higher embolic risk as stratified by the CHA 2 DS 2 -VASc score and having higher purchasing rates (37.1%). Between 2008 and 2010, 29% of patients purchased a vitamin K antagonist, the only available OAC at the time. OAC purchasing increased to 41.4% between 2014 and 2015, with half of the patients purchasing an NOAC. Conclusion:In this real-world, population-based cohort study of patients with newly diagnosed AF, we found a lower than expected rate of OAC prescription within 3 months of diagnosis but an encouraging increase in OAC purchasing over time. The use of NOACs has risen exponentially within just a few years, accounting for a greater pool of patients with being prescribed an OAC.

Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence

“…[40] When it comes to overtreatment, between 0.6% and 79.8% of patients at low risk of stroke who did not need any antithrombotic medication received treatment, which would be considered to be overtreatment. [18,22,26,31,33,35,[43][44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] Recent studies that investigated trends in guideline adherence have shown substantial improvements in guideline adherence over time. Cowan et al [63] reported an increase in the prescription of OACs (by 30.6%) and a decline in the prescription of antiplatelet agents (by 26.8%) over a 10-year period in AF patients at high risk of stroke.…”

Implementation of oral anticoagulation treatment guidelines in patients with newly diagnosed atrial fibrillation

“…However, the rates found in literature vary. Few studies showed lower OAC treatment rates of 50% or less.Those results were demonstrated in early European registry conducted during[2003][2004]6 in the preliminary results from the NCDR PINNACLE registry conducted in the USA during 2008-2012,8 in the part conducted in Asia of RE-LY and GLORIA-AF registries during 2008-2011 and 2011-2014, respectively,7,11 and in a single study from Israel conducted during 2008-2015 10. Lower OAC treatment rates in these studies can be explained by temporal and geographic factors, meaning less treatment during early years after guidelines introduction and less treatment in Asia.…”

“…5 Despite guidelines, OAC treatment was found to be suboptimal among patients with AF. That means there is underuse of OACs among high-risk patients [6][7][8][9][10][11][12][13] while overuse among low-risk patients. [10][11][12][13][14] Contrary to expectations, the contribution of the DOACs introduction has been only modest at first.…”

“…That means there is underuse of OACs among high-risk patients [6][7][8][9][10][11][12][13] while overuse among low-risk patients. [10][11][12][13][14] Contrary to expectations, the contribution of the DOACs introduction has been only modest at first. [9][10][11][12][13][14] However, recent studies emphasized better implementation of guidelines over time and encouraging trend toward expanded use of OACs and specifically DOACs.…”

“…[10][11][12][13][14] Contrary to expectations, the contribution of the DOACs introduction has been only modest at first. [9][10][11][12][13][14] However, recent studies emphasized better implementation of guidelines over time and encouraging trend toward expanded use of OACs and specifically DOACs. 11,13,15,16 Little is known about OAC treatment in AF in Israel.…”