Abstract
ObjectiveNon-vitamin K antagonist oral anticoagulants (NOACs) are proven alternatives to warfarin for preventing stroke in patients with non-valvular atrial fibrillation. We aimed to examine the treatment patterns and patient factors associated with the use of antiplatelet agents, warfarin, and NOACs in clinical practice.MethodsWe conducted a retrospective cohort study using the Korean Health Insurance Review & Assessment Service database. Patients receiving antithrombotics were identified before and after the introduction of NOACs (from August 1, 2013 to December 30, 2014 and July 1, 2015 to November 30, 2016, respectively). Patients were included if they were aged ≥18 years, had an atrial fibrillation diagnosis, and had a CHA2DS2-VASc score ≥2. Treatment pattern was assessed by classifying patients into NOAC, warfarin, or antiplatelet users based on the first date of antithrombotic prescription. Clinical factors associated with the type of antithrombotics chosen were examined using logistic regression analyses.ResultsWe identified 129,465 and 196,243 patients before and after the introduction of NOACs, respectively. The proportion of antiplatelet users was 60.7 and 53.0% before and after the introduction of NOACs, respectively. The proportion of warfarin users was higher in patients with low HAS-BLED score, high CHA2DS2-VASc score, or stroke before the NOAC era. A similar trend was observed for NOAC and warfarin users after the introduction of NOAC. Compared with antiplatelets, warfarin and NOAC uses were significantly associated with CHA2DS2-VASc score and stroke, whereas presence of myocardial infarction (MI) and peripheral arterial disease were significantly associated with antiplatelets prescription. For comparisons between NOAC and warfarin, HAS-BLED and CHA2DS2-VASc scores showed significant associations with NOAC use, whereas comorbidities including MI were significantly associated with warfarin use.ConclusionsThe treatment pattern of antithrombotics did not change with the introduction of NOACs. However, comorbidities served as an important factor in choosing treatment regardless of NOAC entry.
Highlights
Large randomized controlled trials of patients with nonvalvular atrial fibrillation (NVAF) have established that nonvitamin K antagonist oral anticoagulants (NOACs) are as effective as warfarin for preventing stroke/systemic embolism (S/SE) and are safer than warfarin regarding major bleeding (MB) and intracranial hemorrhage [1, 2], making non-vitamin K antagonist oral anticoagulant (NOAC) the recommended first-line drug for stroke prophylaxis in patients with NVAF; their use has grown dramatically worldwide [3–5].Many patients with NVAF have one or more comorbidities
We examined the clinical factors associated with the choice of antithrombotics, such as age, sex, CHA2DS2-VASc score, HASBLED score, Charlson Comorbidity Index (CCI), comorbidities, and medication use, such as non-steroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors (PPIs), H2-receptor antagonists, antiarrhythmics, digoxin, and statins
Female sex, HASBLED score, myocardial infarction (MI), peripheral arterial disease (PAD), diabetes, congestive heart failure, chronic obstructive pulmonary disease (COPD), PPI, H2-receptor antagonist, and antiarrhythmic were significantly associated with the use of antiplatelets, whereas CHA2DS2-VASc score, CCI score, stroke, bleeding, renal disease, digoxin, and statin were significantly associated with warfarin use, both before and after the introduction of NOACs
Summary
Large randomized controlled trials of patients with nonvalvular atrial fibrillation (NVAF) have established that nonvitamin K antagonist oral anticoagulants (NOACs) are as effective as warfarin for preventing stroke/systemic embolism (S/SE) and are safer than warfarin regarding major bleeding (MB) and intracranial hemorrhage [1, 2], making NOACs the recommended first-line drug for stroke prophylaxis in patients with NVAF; their use has grown dramatically worldwide [3–5].Many patients with NVAF have one or more comorbidities. Large randomized controlled trials of patients with nonvalvular atrial fibrillation (NVAF) have established that nonvitamin K antagonist oral anticoagulants (NOACs) are as effective as warfarin for preventing stroke/systemic embolism (S/SE) and are safer than warfarin regarding major bleeding (MB) and intracranial hemorrhage [1, 2], making NOACs the recommended first-line drug for stroke prophylaxis in patients with NVAF; their use has grown dramatically worldwide [3–5]. 20–40% of patients with atrial fibrillation (AF) present with coronary heart disease (CHD), whereas ∼5–10% of patients undergoing percutaneous coronary intervention (PCI) have AF [6]. Antithrombotic treatment patterns may differ depending on the presence of comorbidities. The presence of comorbidities, such as stroke, CHD, and peripheral arterial disease (PAD), may affect treatment patterns of antithrombotics in patients with NVAF [8]. In patients receiving oral anticoagulant (OAC) treatment for prevention of stroke, concomitant treatment with antiplatelets was shown to be associated with an increased rate of MB [10], which may affect treatment patterns of OACs in patients with NVAF
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