Abstract
Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients. To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation. This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020. Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban. Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis. Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P < .001); initiation was lowest in Asian (52.2% [n = 676]) and Black (60.3% [n = 6177]) patients and highest in White patients (62.7% [n = 59 881]). Among anticoagulant initiators, 45 381 (65.2%) used direct-acting oral anticoagulants, varying 7.2 percentage points by race/ethnicity (P < .001); initiation was lowest in Hispanic (58.3% [n = 1470]), American Indian/Alaska Native (59.8% [n = 201]), and Black (60.9% [n = 3763]) patients and highest in White patients (66.0% [n = 39 502). Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian (adjusted odds ratio [aOR], 0.82; 95% CI, 0.72-0.94) and Black (aOR, 0.90; 95% CI 0.85-0.95) patients. Among initiators, the adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic (aOR, 0.79; 95% CI, 0.70-0.89), American Indian/Alaska Native (aOR, 0.75; 95% CI, 0.57-0.99), and Black (aOR, 0.74; 95% CI 0.69-0.80) patients. This cohort study found that in patients with incident atrial fibrillation managed in the VA system, race/ethnicity was independently associated with initiating any anticoagulant therapy and direct-acting oral anticoagulant use among anticoagulant initiators. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients treated in the VA system.
Highlights
Atrial fibrillation (AF) is the most common cardiac rhythm disorder in the United States, affecting up to 6 million adults.[1,2] The Veterans Health Administration (VA) oversees the largest integrated health system in the country, treating nearly 1 million individuals with AF.[3]
Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian and Black patients
The adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic, American Indian/Alaska Native, and Black patients
Summary
Atrial fibrillation (AF) is the most common cardiac rhythm disorder in the United States, affecting up to 6 million adults.[1,2] The Veterans Health Administration (VA) oversees the largest integrated health system in the country, treating nearly 1 million individuals with AF.[3]. Oral anticoagulation (OAC) for nonvalvular AF reduces stroke risk by up to 70% and is the standard of care in patients with moderate to severe stroke risk.[10,11,12] For decades, warfarin was the only OAC available for stroke prevention in patients with AF, but its use was challenging owing to frequent blood monitoring requirements, dosing adjustments, and food and drug interactions.[13,14] A newer class of direct oral anticoagulants (DOACs) with substantially fewer management challenges was initially approved by the US Food and Drug Administration in 2010.15-17 Over time, DOACs have demonstrated superior clinical outcomes, cost effectiveness, safety, and adherence compared with warfarin.[18,19] recent cardiovascular practice guidelines have endorsed DOACs as firstline anticoagulant therapy for eligible patients with AF.[20]
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