Abstract
BackgroundPrevious studies examining the use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) have largely focused on patients newly initiating therapy. Little is known about the prevalence/patterns of switching to DOACs among AF patients initially treated with warfarin.HypothesisTo examine patterns of anticoagulation among patients chronically managed with warfarin upon the availability of DOACs and identify patient/practice‐level factors associated with switching from chronic warfarin therapy to a DOAC.MethodsProspective cohort study of AF patients in the NCDR PINNACLE registry prescribed warfarin between May 1, 2008 and May 1, 2015. Patients were followed at least 1 year (median length of follow‐up 375 days, IQR 154‐375) through May 1, 2016 and stratified as follows: continued warfarin, switched to DOAC, or discontinued anticoagulation. To identify significant predictors of switching, a three‐level multivariable hierarchical regression was developed.ResultsAmong 383 008 AF patients initially prescribed warfarin, 16.3% (n = 62 620) switched to DOACs, 68.8% (n = 263 609) continued warfarin, and 14.8% (n = 56 779) discontinued anticoagulation. Among those switched, 37.6% received dabigatran, 37.0% rivaroxaban, 24.4% apixaban, and 1.0% edoxaban. Switched patients were more likely to be younger, women, white, and have private insurance (all P < .001). Switching was less likely with increased stroke risk (OR, 0.92; 95%CI, 0.91‐0.93 per 1‐point increase CHA2DS2‐VASc), but more likely with increased bleeding risk (OR, 1.12; 95%CI, 1.10‐1.13 per 1‐point increase HAS‐BLED). There was substantial variation at the practice‐level (MOR, 2.33; 95%CI, 2.12‐2.58) and among providers within the same practice (MOR, 1.46; 95%CI, 1.43‐1.49).ConclusionsAmong AF patients treated with warfarin between October 1, 2010 and May 1, 2016, one in six were switched to DOACs, with differences across sociodemographic/clinical characteristics and substantial practice‐level variation. In the context of current guidelines which favor DOACs over warfarin, these findings help benchmark performance and identify areas of improvement.
Highlights
Anticoagulation significantly decreases stroke risk in atrial fibrillation (AF).[1]
The 2019 update to the American College of Cardiology (ACC)/ American Heart Association (AHA)/Heart Rhythm Society (HRS) AF guidelines favor the use of direct oral anticoagulant (DOAC) over warfarin for stroke prevention in nonvalvular AF with a class 1A recommendation.[4]
The National Cardiovascular Disease Registry (NCDR) PINNACLE registry is a prospective outpatient quality improvement registry that was created by the ACC in 2008.10 In this registry, both academic and private practices collect longitudinal data pertaining to the care of patients with AF, coronary artery disease, hypertension, and heart failure
Summary
Anticoagulation significantly decreases stroke risk in atrial fibrillation (AF).[1] warfarin was previously the standard treatment for stroke prevention in AF, direct oral anticoagulant (DOAC) medications have been approved for nonvalvular AF since 2010 Compared to warfarin, these medications have been shown to provide more consistent anticoagulant effect, substantially reduce the risk of intracranial hemorrhage, have fewer interactions with other drugs/food, and do not require international normalized ratio (INR) monitoring.[2,3] As a result, the 2019 update to the American College of Cardiology (ACC)/ American Heart Association (AHA)/Heart Rhythm Society (HRS) AF guidelines favor the use of DOACs over warfarin for stroke prevention in nonvalvular AF with a class 1A recommendation.[4]. We hypothesized that there would be significant disparities in switching patterns and substantial patient/practice-level variations
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