Anticoagulant Prescription Research Articles

Multimorbidity in atrial fibrillation for clinical implications using the Charlson Comorbidity Index

BackgroundPredicting survival in atrial fibrillation (AF) patients with comorbidities is challenging. This study aimed to assess multimorbidity in AF patients using the Charlson Comorbidity Index (CCI) and its clinical implications. MethodsWe analyzed 451,368 participants from the Korea National Health Insurance Service-Health Screening cohort (2002−2013) without prior AF diagnoses. Patients were categorized into new-onset AF and non-AF groups, with a high CCI defined as ≥4 points. Antithrombotic treatment and outcomes (all-cause death, stroke, major bleeding, and heart failure [HF] hospitalization) were evaluated over 9 years. ResultsIn total, 9.5% of the enrolled patients had high CCI. During follow-up, 12,241 patients developed new-onset AF. Among AF patients, antiplatelet drug use increased significantly in those with high CCI (adjusted odds ratio [OR] 1.05, 95%confidence interval [CI] 1.02–1.08, P < .001). However, anticoagulants were significantly less prescribed in patients with high CCI (OR 0.97, 95%CI 0.95–0.99, P = .012). Incidence of adverse events (all-cause death, stroke, major bleeding, HF hospitalization) progressively increased in this order: low CCI without AF, high CCI without AF, low CCI with AF, and high CCI with AF (all P < .001). Furthermore, high CCI with AF had a significantly higher risk compared to low CCI without AF (all-cause death, adjusted hazard ratio [aHR] 2.52, 95% CI 2.37–2.68, P < .001; stroke, aHR 1.43, 95% CI 1.29–1.58, P < .001; major bleeding, aHR 1.14, 95% CI 1.04–1.26, P = .007; HF hospitalization, aHR 4.75, 95% CI 4.03–5.59, P < .001). ConclusionsHigh CCI predicted increased antiplatelet use and reduced oral anticoagulant prescription. AF was associated with higher risks of all-cause death, stroke, major bleeding, and HF hospitalization compared to high CCI.

Patterns of Anticoagulation Use and All-Cause of Mortality in Cancer Patients with Atrial Fibrillation.

There is uncertainty regarding the clinical benefit of anticoagulant (AC) treatment in patients with cancer with atrial fibrillation (AF). We aimed to evaluate the distribution and patterns of AC use and its impact on all-cause mortality in cancer patients with AF. A total of 1,653 patients with cancer diagnosed with AF were included in this retrospective cohort analysis. Multivariable logistic regression was applied to identify the clinical predictors of anticoagulant prescription. Kaplan-Meier curve with a log-rank test was used to compare the probability of survival between the AC and non-AC groups. Multivariate Cox proportional hazard regression models were implemented to evaluate the influences of various variables on all-cause death. Of 1,653 patients with cancer with AF, 971 (58.7%) did not receive a prescription for AC. Among patients with CHA2DS2-VASC ≥2 in men or ≥3 in women and HAS-BLED <3, 56.5% were not prescribed AC. Rivaroxaban and warfarin are more frequently used than dabigatran, mainly in patients with lung and breast cancer. Over a median follow-up of 36 months, 776 deaths were identified. The Kaplan-Meier curve suggested that patients with AC prescriptions had better clinical outcomes. On multivariate Cox proportional risk regression analysis, AC prescription was significantly associated with a lower risk of all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P = 0.002). The prescription of anticoagulants in patients with cancer with AF was suboptimal. AC prescription at discharge was associated with a decreased risk of all-cause mortality. This study highlights the importance of AC prescriptions in patients with cancer with AF.

Recovery of left ventricular ejection fraction in Takotsubo Syndrome

Abstract Introduction Takotsubo Syndrome (TTS) is a condition of transient left ventricular dysfunction that is typically triggered by emotional or physical stress. Left ventricular ejection fraction (LVEF) recovery in TTS occurs over a wide-range interval, varying from days to weeks. Purpose Our purpose was to access the prognostic impact of delayed recovery of LVEF in patients with TTS. Methods We performed a retrospective analysis of patients admitted in a single centre between 2008 and 2022 with the diagnosis of TTS, with a LVEF &amp;lt;50% at admission. Patients were divided into two groups: Group A- patients with the recovery of ejection fraction during hospitalization (LV EF ≥ 50% at the pre-discharge echocardiogram) and Group B- patients that had a delay in recovery, with LV EF &amp;lt;50% at the pre-discharge echocardiogram. Major adverse cardiovascular events (MACCE) included heart failure hospitalization, cardiovascular mortality, stroke and TTS recurrence. Results We included 63 pts, 88,9% females, mean age of 69,38 ±12,5 years. Group A included 27 pts, with a median LV EF of 37% (IQR 33-41) and group B included 36 pts with a median LV EF of 36% (IQR 33-38,8), with no statistically significant difference between the two groups (p= 0,347). The median pre-discharge LV EF was 60,0% (IQR 56-65,6) in group A and 42,0% (IQR 37-47) in group B (p&amp;lt;0,005). The hospitalization length (HL)was similar between the two groups (mean HL of 7,9 ±7,8 in group A versus 8,1 ±8,4 days in group B, p= 0,93). The two groups were similar in terms of basal characteristics, with more prevalence of psychiatric disease in group A (13,9% vs 33,3%, p= 0,066). We found no statistically differences in clinical presentation and evolution during hospitalization (Killip class, cardiogenic shock, ventricular arrhythmias) and in the rates of concomitant coronary artery disease (14,8% group A versus 26,5% group B, p= 0,270). Also, the in-hospital medication and at discharge (Angiotensin-converting enzyme inhibitors, beta blockers, spironolactone and aspirin) were identical between the two groups. There was a tendency for more prescription of anticoagulants at discharge in group B (45,7% versus 22,2%, p = 0,055). During a median follow-up of 41,0 months (IQR 14,0-54,5), group B had a higher rate of MACCE (34,4% versus 20,0%, log rank p= 0,033). In a multivariate analysis, after adjusting for possible confounders, delayed recovery of LV EF was an independent predictor of MACCE with a HR 6,1 (95% CI: 1,50-24,9, p= 0,012) (Fig.1). Conclusions In this population, delayed recovery of LV EF in TTS was an independent predictor of major adverse cardiovascular events. These findings suggest that this population should be targeted in clinical trials to investigate possible interventions and these patients should have a closer follow-up.

10-year trends in oral anticoagulation therapies and ischemic stroke among 157,583 patients with non-valvular atrial fibrillation

Abstract Purpose Initiation of oral anticoagulation therapy (OAC) for stroke prevention in patients with atrial fibrillation (AF) is often suboptimal in clinical practice. We aimed to describe trends in OAC uptake and incidence of ischemic stroke over the past decade. Methods We retrospectively analyzed consecutive patients with non-valvular (NV) AF between January 2012 and July 2022 from 16 public hospitals. Annual incidence of AF was the number of new AF cases as proportion of adult population reported by Census and Statistics Department. Prescription of OAC (vitamin K antagonist (VKA) and direct oral anticoagulants (DOAC)) were recorded. OAC uptake was defined as initiation of OAC within 12 months from AF diagnosis. Incidence of ischemic stroke was calculated for both incident and prevalent AF cohorts over time. Logistic regression was conducted to identify predictors of OAC uptake. Results 157,583 NVAF patients (mean age 76.6±12.5 and female 49.6%) with mean CHA2DS2VASC 2.6±1.3 were identified. Between 2012 and 2022, incidence of new AF was steady across the years with mean of 0.19%±0.03% (range 0.16% to 0.24%) per year. OAC prescription increased from 15.3% to 46.0% and the incidence of ischemic stroke decreased significantly from 4.0% to 0.6% over the last decade (both p for trend &amp;lt;0.01). DOAC use increased steadily from 6.2% to 41.0% whereas VKA decreased from 9.1% to 3.5% (Figure). Mean time from AF diagnosis to OAC prescription was 0.6±1.6 months. Of all patients prescribed OAC, 40.8% initiated OAC within 1 month after AF diagnosis. CHA2DS2VASC scores ≥4 was associated with higher likelihood of OAC uptake (OR=1.74 (95%CI: 1.69-1.78). Conclusion Our real-world data demonstrated steady incidence of new NVAF diagnosis with increasing trend in OAC prescription, predominantly DOAC and decreasing incidence ischemic stroke over the last decade. However, overall utilization of OAC for stroke prevention remains suboptimal.

Oral anticoagulant use and outcomes in Asian patients with atrial fibrillation in the GLORIA-AF Registry

Abstract Background Ethnic differences in the management and outcomes of patients with atrial fibrillation (AF) have been shown in previous studies, but available data is still limited, although urgently needed. Purpose to analyse oral anticoagulant (OAC) prescription, OAC discontinuation, and long-term risk of major outcomes in Asian patients with AF, using data from a global prospective cohort study. Methods Using data from the GLORIA-AF Registry Phase II and III, we analysed patients according to their self-reported ethnicity (Asian vs. Non-Asian), and according to Asian ethnic subgroup (i.e. Chinese, Japanese, Korean and other Asian). Odds of OAC prescription were analysed through multivariable logistic regression, while the risk of OAC discontinuation and adverse outcomes were analysed through multivariable Cox-regression model. Primary outcome of this analysis was defined as the composite of all-cause death and major adverse cardiovascular events (MACE). Results 34,421 AF patients were included (70.0±10.5 years, 45.1% females, 6,900 (20.0%) Asian). Compared to Non-Asian subjects, prescription of OAC and non-vitamin K antagonist oral anticoagulant (NOAC) was lower in Asian subjects (Odds Ratio [OR] and 95% Confidence Intervals (CI): 0.23 [0.22-0.25] and 0.66 [0.61-0.71], respectively; Figure 1), but higher in the Japanese subgroup. Asian ethnicity was also associated with OAC discontinuation (Hazard Ratio [HR] and [95%CI]: 1.79 [1.67-1.92]), and lower risk of the primary composite outcome (HR [95%CI]: 0.86 [0.76-0.96]; Figure 2). Among the secondary outcomes, Asian patients had also higher risk of thromboembolism and intracranial haemorrhage, and lower risk of major bleeding events. Conclusions In this large, contemporary cohort of patients with AF, Asian subjects received suboptimal management of thromboembolic risk, and showed a peculiar long-term risk of adverse outcomes. Integrated and appropriate treatment of these patients is crucial to improve their prognosis.Figure 1Figure 2

Patterns of comorbidities and influence on the natural history of patients with atrial fibrillation: a latent class analysis from a prospective observational european AF registry

Abstract Background Patients with Atrial Fibrillation (AF) usually present with multiple comorbidities at diagnosis, and their combinations heterogeneously influence management and outcomes. While the effect of multimorbidity on the natural history of AF is well-known, the influence of patterns of multimorbidity is far less understood. Purpose To identify and analyse subgroups of AF patients according to their comorbidities, through a latent class analysis of a contemporary cohort of AF patients. Methods We used data from a European-wide prospective observational AF registry, and performed a latent class analysis, according to the presence of chronic diseases (including cardiovascular, respiratory, metabolic and other conditions); class membership was assigned according to the modal posterior probability. Multivariable logistic regression models were used to analyse odds of receiving oral anticoagulant (OAC) prescription and type of OAC received; the risk of the primary outcome of all-cause death and MACE was assessed using multivariable Cox-regression model. Results 9,613 AF patients were included in this analysis (mean age 68.9 ± 11.4 years, 40.2% females), and were grouped in 5 classes, which were different according to the burden of comorbidities: low morbidity pattern (46.1%), cardiovascular pattern (25.0%), metabolic pattern (11.3%), heart failure pattern (9.7%) and multisystemic pattern (8.0%) (Figure 1). Patients in the multisystemic pattern were older and more frequently frail and with polypharmacy compared to other classes. Compared to the low morbidity pattern, odds of receiving OAC was lower in those with cardiovascular pattern (OR [95%CI]: 0.73 [0.62-0.86]), heart failure pattern (OR [95%CI]: 0.60 [0.48-0.75] and multisystemic pattern (OR [95%CI]: 0.28 [0.22-0.36]), while those with metabolic pattern were more likely prescribed OAC (OR [95%CI]: 1.55 [1.20-2.00]). All patterns were less likely treated with NOAC compared to VKA (Figure 2). When analysing the risk of the primary composite outcome, all patterns except for the metabolic pattern were associated with higher hazard of events, with highest magnitude observed for the heart failure pattern (HR 2.68 [95%CI: 2.22-3.25]) and the multisystemic pattern (HR 2.67 [2.13-3.35]) (Figure 2). Conclusions Comorbidities are heterogeneously distributed in the AF population, and different phenotypes of AF patients may be identified according to the combination of other chronic diseases, with different OAC use for stroke prevention and an unequal impact on long-term prognosis. These findings reinforce the need for tailored preventive strategies to improve outcomes in AF patients, especially those with multimorbidity.Figure 1Figure 2

Prevalence, adequacy and adherence of anticoagulation for stroke thromboprophylaxis in minority patients with atrial fib referred for transthyretin cardiac amyloidosis screening: The SCAN-MP Study

Abstract Introduction/Background Atrial fibrillation (AF) is the most common arrhythmia in adults, confers a 5-fold increase in risk of stroke, and is present in up to 50% of patients with transthyretin cardiac amyloidosis (ATTR-CA). 1,2 When present in ATTR-CA, AF is associated with a significant risk of stroke and systemic thromboembolism, even independent of CHA2DS2VASc score. 2-4. Current guidelines advocate the use of oral anticoagulant therapy in all patients with ATTR-CA and AF, without a contraindication for such treatment. Up to 50% of patients with an escalated risk for systemic thromboembolism may not be receiving appropriate anticoagulation, but less is known about patterns and adequacy of anticoagulation in minority patients, specifically Black/Hispanic patients with suspected amyloidosis and AF. 5,6. Methods We conducted a retrospective study of patients in SCAN-MP (Screening for Cardiac Amyloidosis with Nuclear Imaging in Minority Populations) who were ≥60 years of age with heart failure, Black or Hispanic, with an EF &amp;gt;30% and increased left ventricular wall thickness, (n=431) from 4 large urban hospitals who had documented AF in their medical records. We assessed the prescription of anticoagulation in participants stratified by the CHA2DS2VASc score and whether they received an appropriate dose (versus inappropriately low or high dose, when adjusted for renal function for dabigatran, edoxaban, and rivaroxaban; for renal function, age, and weight for apixaban). Results 122 subjects (28.3%) had a history of atrial fibrillation and of that number, 25.4% (n=31) were either not receiving any treatment (n=14) or only received a single anti-platelet therapy (n=17) for stroke thromboprophylaxis. Among participants with AF, patients with a CHA2DS2VASc of 6-9 (n=27), 21 patients (77.8%) were receiving an oral anticoagulant (either VKA or DOAC) either alone or in combination with antiplatelet therapy (Table 1). Among patients with CHA2DS2VASc of 2-5 (n=95), 70 patients (73.7%) were receiving such therapy. Among patients receiving a DOAC (n=74), dosing was incorrect in 20.3% (n=15). There were a significant proportion of patients receiving antiplatelet therapy in combination with oral anticoagulant (n=30, 24.5%). Among these patients receiving both therapies, only about half (n=16, 53.3%) had some form of vascular disease, coronary artery disease and/or peripheral arterial disease (Table 2). Conclusions These data suggest that thromboprophylaxis in Black and Hispanic patients with AF and suspected amyloidosis with heart failure is better than the often ≤50% historically reported in the literature. 6 Nearly ¼ of patients were receiving both antiplatelet and anticoagulant therapy, even though only half had documentation of vascular disease. Factors underlying this observation requires additional study, but the indication for such dual anti-thrombotic therapy is limited, may be associated with harm 7, and is an opportunity for improvement.Anti-thrombotic regimens in patientsTable 2:Frequency of vascular disease

The impact on the elapsed time to care and outcomes of a clinician-to-clinician electronic consultation program in patients diagnosed or suspected atrial fibrillation in primary care

Abstract Background An early diagnosis and early initiation of oral anticoagulants (OAC) are main determinants for outcomes in patients with atrial fibrillation (AF). Clinician-to-clinician electronic consultations (e-consultations) program as the first step in the ambulatory care organization for the general practitioner (GPs) referrals to cardiologist may improve health care access by reducing the elapsed time for cardiology care compared with a face-to-face consultation for all the referrals. Objective To evaluate the effect on outcomes of a reduced elapsed time to care after a clinician-to-clinician e-consultations program implementation (2013–2019) in comparison with previous in-person consultation (2010–2012) in the outpatient health care management in a Cardiology Department. Methodology We included 10,488 patients referred by general care practitioners for cardiology consultation with confirmed or suspected AF from 1 January 2010, to 31 December 2019. Until 2012, all patients were attended with an in-person consultation (2010–2012). In 2013, we instituted an e-consult program (2013–2019) for all primary care referrals to cardiologists that preceded patient's in-person consultation when considered. The shared electronic patient dossier (EPD) was available between GP and cardiologist, and any clinical comment and change in therapy advice from cardiologist was directly implemented in this EPD. Results During the e-consultation period (2013–2019) were referred 6627 patients by GPs to cardiology versus 3861 during the in-person consultation (2010– 2012). The e-consultation implementation was associated with a reduction in the elapsed time to anticoagulation prescription (177.6 ±8.9 vs. 22.5 ±8.1 days,p &amp;lt; .001) (Figure 1, A), and an increase of OAC use (61% [95% IC: 19.6%–102.4%], p &amp;lt; .001) (Figure 1, B). The e-consult program implementation was associated with a reduction in the 1-year CV mortality (.48 [95% CI: .30–.75]) and all-cause mortality (.42 [95% CI: .29– .62]). The OAC reduces the stroke mortality (.15 [95% CI: .06–.39]) and CV mortality (.43 [95% CI: .29–.62]) and all-cause mortality (.23 [95% CI: .17–.31]) (Figure 2). Conclusion A shared EPD-based clinician-to-clinician e-consultation program significantly reduced the elapsed time for cardiology consultation and initiation of OAC. The implementation of this program was associated with a lower risk of stroke, cardiovascular and all-cause mortality.

Abstract 12324: Current Trends in Anticoagulation, Referral and Utilization of Procedures for Rhythm Control for Atrial Fibrillation

Introduction: Atrial fibrillation (AF) can reduce quality of life and cause thromboembolic events, heart failure and death. Prior studies have identified disparities in the treatment of AF based on sex, race, and ethnicity. Hypothesis: There will be disparities in procedures for rhythm control (RC) based on sex, race and ethnicity. Methods: Cohorts of patients with new AF from 2016 to 2021 were identified with 1 year follow up to identify referrals, anticoagulant prescription, and procedures for RC. We calculated the proportion of patients with each outcome overall stratified by sex and race/ethnicity. We used logistic regression to compare outcomes across sex and race/ethnicity after adjustment for confounding variables. Results: We identified 2,919 patients with a new onset AF. The mean age: 68 years, 53% were male, 66% had Medicare, 69% self-identified as White, 23% as Black, and 3% as Hispanic. There was no difference in referral rates between men and women. Compared to White patients, Black and Hispanic patients were more likely to be referred to Cardiology and more likely to complete a visit. Prescription of anticoagulants was high (83%) and did not differ between men and women (84% vs. 82%, p = 0.65). Compared to White patients, Black and Hispanic patients were more likely to receive a prescription for anticoagulation (86% and 88% vs. 81%, p = 0.006). Women were significantly less likely to receive cardioversion or ablation compared to men (17% vs. 25%, p &lt; 0.001). Similarly, Blacks and Hispanics were significantly less likely to receive procedures compared to Whites (17% vs. 23%, p = 0.01). Conclusions: Despite equal attendance at Cardiology visits, women and Black or Hispanic patients were significantly less likely to receive cardioversion or ablation compared to men and Whites respectively.

Abstract 12454: Weak Supervision Enables Scalable Post-Market Surveillance on Medical Wearables

Introduction: With the advent of consumer-facing devices that can render atrial fibrillation (AF) pre-diagnosis, medical wearables now have the potential to affect diagnosis rates and medical care. Post-market surveillance is necessary to understand the impact of wearables on patient outcomes and health care utilization, but is hindered by the lack of codified terms in EHR that capture wearable use. Research Questions: Constructing a post-market surveillance system therefore requires a classifier that identifies mentions of AF pre-diagnosis in unstructured EHR data. However, fine-tuning classifiers require large, hand-labeled training sets that can be costly to generate. It is unclear whether a scalable surveillance system could be built for wearables. Methods: Two weakly-supervised approaches were evaluated to reduce clinical note labeling overhead: one using programmatic codes, and the other using prompts to large language models (LLMs). Probabilistically labeled notes were then used to fine-tune a classifier, which identified patients with AF pre-diagnosis mentions. A retrospective cohort study was conducted, where the characteristics and care patterns of patients identified by the classifier were compared against those who did not receive pre-diagnosis. Results: Label model derived from prompt-based labeling heuristics using LLMs (precision = 0.67, recall = 0.83, F1 = 0.74) nearly achieved the performance of code-based heuristics (precision = 0.84, recall = 0.72, F1 = 0.77), while cutting down the cost to create a labeled training set. The classifier learned on the labeled notes accurately identified patients with AF pre-diagnosis (precision = 0.85, recall = 0.81, F1 = 0.83). Those patients who received pre-diagnosis exhibited different demographic and comorbidity characteristics, and were enriched for anticoagulation and eventual diagnosis of AF. At the index diagnosis, existence of pre-diagnosis did not stratify patients on clinical characteristics, but did correlate with anticoagulant prescription. Conclusion: Our work establishes the feasibility of an EHR-based surveillance system for wearable devices that render AF pre-diagnosis. Weakly-supervised approaches can be effective in reducing test set labeling costs.

Abstract 16063: African American's Are Prescribed Direct Oral Anticoagulants at Lower Rate Than White Patient's in an Inpatient Cohort With Diagnosis of Atrial Fibrillation

Introduction: Previous studies have demonstrated racial disparities in the treatment of atrial fibrillation (AF). Potential explanations for disparities in care include cost and insurance coverage issues. This has not been examined in relation to anticoagulation (AC) therapy for thromboembolic prophylaxis of AF in a more contemporary practice using an inpatient cohort. Hypothesis: For hospitalized patients with AF, is there disparity in the rate of prescription of direct oral anticoagulant (DOAC) therapy at discharge for Black compared to White patients? Methods: A single-center retrospective query of all patients hospitalized at a University Hospital with a primary or secondary diagnosis of “AF” in 2022 and a prescription for AC at time of discharge was performed using EPIC. Baseline characteristics and AC prescription were compared between Black and White patients using the χ2 test for categorical variables and t test for continuous variables. Results: There were 275 patients that met the inclusion criteria. Demographics were 38.2% female, 66.5% White, and 14.9% Black (Table). DOAC was prescribed at discharge for 66.1% of White and in 55.0% of Black patients (p=0.01). The distribution of type of AC prescribed at discharge is shown (Figure). Conclusions: There is an ongoing racial disparity in the rate of DOAC prescription in hospitalized patients with AF, despite similar insurance status. Further investigation into underlying reasons for these differences and ways to eliminate disparities is warranted.

Abstract 13115: Association of Hospital Racial Composition and Anticoagulation for Atrial Fibrillation: A Nationwide Study

Introduction: Anticoagulation reduces stroke risk in atrial fibrillation (AF). Patient-level studies show significant Black-White disparities in any anticoagulant and direct oral anticoagulant (DOAC) prescribing. Little is known about whether such disparities exist at the hospital level, thus we examined the association of hospital racial composition and anticoagulant initiation. Hypothesis: Hospitals with higher rates of Black patients would have lower anticoagulation. Methods: We conducted a retrospective cohort study of patients with incident AF treated at a VA medical center (VAMC) from 2018-2021. Our independent variable was hospital racial composition, defined by the proportion of Black patients cared for at a VAMC, with Quartile 1 (Q1) being the lowest, and Quartile (Q4) being the highest. We used a multivariable logistic regression model, adjusting for clinical factors (e.g., stroke and bleeding risk), year of diagnosis, and region, to estimate the odds of any anticoagulant and/or DOAC initiation by hospital racial composition. Results: We identified 86,436 patients with incident AF at 140 VAMCs, 10.5% Black, 89.5% White, mean age 73 years. Patients in Q4 were younger with similar stroke and bleeding risk to those in Q1. Overall, any anticoagulant use was 73.4% in Q1 and 71.4% in Q4 and lower for Black vs. White patients in both quartiles (Q1: 68.9% vs. 73.5%; Q4: 69.1 vs. 72.0%). The odds of initiating any anticoagulant overall were lower in Q1 hospitals compared to Q4: adjusted odds ratio (aOR): 0.85; 95% CI 0.73-0.99; p=0.04. DOAC use was similar in Q1 and Q4 (67.6% vs. 67.2%) though lower for Black vs. White patients in both quartiles (Q1: 57.4% vs. 67.7%; Q4: 63.3 vs. 68.5%). There was no significant difference overall in the odds of initiating DOAC in Q1 hospitals compared to Q4, aOR: 0.96; 95% CI 0.83-1.12; p=0.61. Conclusions: In a national study of patients with AF in the VA, we observed a significant difference in any anticoagulant but not DOAC initiation by hospital racial composition. Racial differences in anticoagulant use existed across quartiles, as in prior work. These data suggest that racial disparities in anticoagulant use in the VA, a safety net health system, may require local rather than national-level solutions alone to eliminate them.

Cost-Effectiveness of AF Screening With 2-Week Patch Monitors: The mSToPS Study.

The mSToPS study (mHealth Screening to Prevent Strokes) reported screening older Americans at risk for atrial fibrillation (AF) and stroke using 2-week patch monitors was associated with increased rates of AF diagnosis and anticoagulant prescription within 1 year and improved clinical outcomes at 3 years relative to matched controls. Cost-effectiveness of this AF screening approach has not been explored. We conducted a US-based health economic analysis of AF screening using patient-level data from mSToPS. Clinical outcomes, resource use, and costs were obtained through 3 years using claims data. Individual costs, survival, and quality-adjusted life years (QALYs) were projected over a lifetime horizon using regression modeling, US life tables, and external data where needed. Adjustment between groups was performed using propensity score bin bootstrapping. Screening participants (mean age, 74 years, 41% female, median CHA2DS2-VASC score 3) wore on average 1.7 two-week monitors at a mean cost of $614/person. Over 3 years, outpatient visits were more frequent for monitored than unmonitored individuals (difference 190 per 100 patient-years [95% CI, 82-298]), but emergency department visits (-8.3 [95% CI, -12.6 to -4.1]) and hospitalizations (-15.2 [CI, -22 to -8.6]) were less frequent. Total adjusted 3-year costs were slightly higher (mean difference, $1551 [95% CI, -$1047 to $4038]) in the monitoring group. In patient-level projections, the monitoring group had slightly greater quality-adjusted survival (8.81 versus 8.71 QALYs, difference, 0.09 [95% CI, -0.05 to 0.24]) and slightly higher lifetime costs, resulting in an incremental cost-effectiveness ratio of $36 100/QALY gained. With bootstrap resampling, the incremental cost-effectiveness ratio for monitoring was <$50 000/QALY in 64% of study replicates, and <$150 000/QALY in 91%. Using lifetime projections derived from the mSToPS study, we found that AF screening using 2-week patch monitors in older Americans was associated with high economic value. Confirmation of these uncertain findings in a randomized trial is warranted. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02506244.

Trends in Atrial Fibrillation Management—Results from a National Multi-Center Urgent Care Network Registry

Background: Atrial fibrillation (AF) is a common diagnosis in patients presenting to urgent care centers (UCCs), yet there is scant research regarding treatment in these centers. While some of these patients are managed within UCCs, some are referred for further care in an emergency department (ED). Objectives: We aimed to identify the rate of patients referred to an ED and define predictors for this outcome. We analyzed the rates of AF diagnosis and hospital referral over the years. Finally, we described trends in patient anticoagulation (AC) medication use. Methods: This retrospective study included 5873 visits of patients over age 18 visiting the TEREM UCC network with a diagnosis of AF over 11 years. Multivariate analysis was used to identify predictors for ED referral. Results: In a multivariate model, predictors of referral to an ED included vascular disease (OR 1.88 (95% CI 1.43–2.45), p &lt; 0.001), evening or night shifts (OR 1.31 (95% CI 1.11–1.55), p &lt; 0.001; OR 1.68 (95% CI 1.32–2.15), p &lt; 0.001; respectively), previously diagnosed AF (OR 0.31 (95% CI 0.26–0.37), p &lt; 0.001), prior treatment with AC (OR 0.56 (95% CI 0.46–0.67), p &lt; 0.001), beta blockers (OR 0.63 (95% CI 0.52–0.76), p &lt; 0.001), and antiarrhythmic medication (OR 0.58 (95% CI 0.48–0.69), p &lt; 0.001). Visits diagnosed with AF increased over the years (p = 0.030), while referrals to an ED decreased over the years (p = 0.050). The rate of novel oral anticoagulant prescriptions increased over the years. Conclusions: The rate of referral to an ED from a UCC over the years is declining but remains high. Referrals may be predicted using simple clinical variables. This knowledge may help to reduce the burden of hospitalizations.

Dynamics of Prescribing Antithrombotic Therapy to Patients with Atrial Fibrillation Hospitalized for Myocardial Infarction in 2016–2021

INTRODUCTION: At present, the issue of optimal antithrombotic therapy (ATT) in patients with myocardial infarction (MI) and atrial fibrillation (AF) has not been finally resolved, it requires an individual approach and is of interest for study.&#x0D; AIM: To study the dynamics of prescribing ATT to patients with AF of non-valvular etiology hospitalized in cardiology hospital in 20162021 for MI.&#x0D; MATERIALS AND METHODS: The study included 599 patients with MI and AF: in 20162017 104 patients, in 20182019 256 patients, in 20202021 239 patients. The median and interquartile range of age of patients hospitalized in 20162017 were 70 (61.0; 78.0) years, in 20182019 71 (65.0; 79.3) years, in 20202021 72 (65.0; 80.0) years, p = 0.09.&#x0D; RESULTS: In 20162017, 76.9% of patients with MI and AF were prescribed double antiplatelet therapy (DAPT) from the first day of hospitalization; 16.3% of patients were prescribed therapy with oral anticoagulants (OACs), here, in 6.7% as part of triple ATT, in 8.7% as part of double ATT (OACs + antiplatelet agent), in 1.0% as monotherapy with OACs; in 3.8% monotherapy with an antiplatelet agent was prescribed; in 2.9% of cases ATT was not prescribed. In 20182019, DAPT was used in 37.9% of cases; therapy with OACs in 54.7% of cases: in 44.9% cases as part of triple ATT, in 9.8% as part of double therapy; in 7.4% of cases monotherapy with antiplatelet agent was prescribed. In 20202021, DAPT was prescribed in 15.9% of cases; therapy with OACs in 74.5%, of them in 59.8% triple АТТ, in 14.2% double АТТ; monotherapy with an antiplatelet agent - in 7.5%; in 1.7% АТТ was not prescribed.&#x0D; CONCLUSION: In the study, the frequency of prescription of triple ATT to patients with AF and MI in 20202021 increased 1.3 times as compared to 20182019, and 8.9 times as compared to 20162017 and made 59.8% (p 0.001 for all periods). The frequency of OAC also increased 1.3 times as compared to 20182019 and 4.6 times as compared to 20162017 and made 74.5% (p 0.001 for all periods). This dynamics of increase in the frequency of prescription of oral anticoagulants to patients with a combination of AF and MI should be considered a positive result of introduction of the Clinical recommendations in the treatment of cardiologic patients.

Direct Oral Anticoagulant Use Early After Cardiac Surgery: A Retrospective Cohort Study

BackgroundThere is limited literature guiding the prescribing of direct oral anticoagulants (DOACs) early after cardiac surgery as this population has been excluded from landmark randomized controlled trials. This study aims to determine the rate of in-hospital DOAC use compared with warfarin early after cardiac surgery, evaluate factors associated with DOAC use, determine difference in postoperative length of stay, and characterize bleeding events. MethodsA retrospective cohort study was conducted in adult patients with indications for anticoagulation and receiving either a DOAC or warfarin after cardiac surgery during their index hospitalization. Patients were excluded if they had any contraindications to DOAC use. The primary outcome was the proportion of patients discharged on a DOAC compared with warfarin. ResultsOf included 210 patients, 30% received DOACs and 70% received warfarin on discharge. The most common DOAC used was apixaban (74.6%), and median postoperative day of initiation was 5 days. Patients receiving DOACs were older (70.8 vs 68.0 years), had less valvular heart disease (38.1% vs 63.9%), were more likely to be on DOACs preoperatively (50.8% vs 31.3%), and were more likely to have undergone coronary artery bypass graft alone (54.0% vs 24.5%) compared with those on warfarin. Postoperative length of stay (7 vs 9 days; P = 0.59) and in-hospital bleeding (1.6% vs 2.0%; P = 1.00) did not differ between DOAC and warfarin groups. ConclusionsAt a quaternary referral centre for cardiac surgery, DOACs were used in approximately one-third of patients with an indication for anticoagulation early after cardiac surgery.

330 Evaluating anticoagulant prescribing errors in older adults in a rehabilitation setting

Abstract Background Anticoagulant use is common in older adults for the prevention or treatment of a number of conditions, most commonly Venous Thrombo-Embolism (VTE) or to prevent stroke in atrial fibrillation. Our audit aimed to review anticoagulation prescribing practices, identify errors and areas for improvement. Methods The initial retrospective audit of all inpatients in a medical gerontology ward took place from 15/11/2022–30/12/22. Data collected included age, sex, weight, renal profile, anticoagulation type, dose and indication. Information was collected from medication records, clinical notes and online laboratory system. After initial audit, multiple education sessions were conducted with the medical team. Re-audit of all inpatients occurred from 05/04/2023–25/04/2023. The guidelines used were the HSE Prescribing Tips for Anticoagulation and local Hospital Guidelines on VTE prophylaxis. Results The initial audit of 73 patients showed 15% (11) rate of prescribing error with 7 subtherapeutic and 4 supratherapeutic doses. Of these 11 errors, 4 doses were corrected recently prior to audit. Average age was 82.6 (64–100) and 55% (40) were female. The re-audit of 51 patients showed the rate of error improved to 7.84%(4) with 4 supratherapeutic doses. 1 dose was corrected on admission and 5.88%(3) required dose adjustment due to fluctuations in weight and renal function throughout admission. Average age was 83.1(66–103) and 69%(35) were female. Conclusion The re-audit demonstrated ongoing education sessions reduces prescribing error with a 48% reduction. However ongoing monitoring throughout admission is required to account for fluctuations in weight and renal function. Suggestions for further improvements include ongoing regular education sessions with the medical team. Further sessions are planned with the wider multidisciplinary team members to highlight importance of regularly monitoring weight and renal function and medication dosages. This audit also reinforces the importance of the role of pharmacist in the multidisciplinary team in Rehabilitation Units and would support regular pharmacist input on an regular basis.

Budget and health impact of switching eligible patients with atrial fibrillation to lower- dose dabigatran

ABSTRACT Objectives: To assess the comparative budget and health impact of lower-dose dabigatran versus reduced doses of apixaban and rivaroxaban in atrial fibrillation (AF) patients eligible for a lower-/reduced-dose due to individual patient characteristics in the Netherlands. Methods: A budget impact model was developed in accordance with ISPOR guidelines. A 3-year-time horizon was considered, and analyses were conducted from a Dutch healthcare payer’s perspective. The model applies published data to local AF-epidemiology, allowing calculations to estimate clinical events (strokes and haemorrhages) and costs. The analyses were based on real-world outcomes from patients with AF receiving a first direct oral anticoagulant (DOAC) prescription for low-dose dabigatran (110 mg) and a reduced dose of apixaban (2.5 mg) or rivaroxaban (15 mg). Two situations of switching treatments from one to another DOAC were modelled: switching from apixaban to dabigatran and from rivaroxaban to dabigatran. Base case results were given as savings per 100 patient-year, per total Dutch population, and events avoided. A univariate sensitivity analysis was conducted to explore the uncertainty around epidemiological and event costs input data. Scenario analyses were performed to estimate the effect of different market shares and potential price reductions due to future patent expiry for the total real-world population from the Netherlands. Results: The 3-years outcomes of switching patients eligible for a lower-/reduced-dose due to individual patient characteristics from apixaban or rivaroxaban to dabigatran resulted in cost savings estimated at €157 or €72 thousand per 100 patient-years, respectively, or €146 million per total Dutch population. Looking into the clinical events, dabigatran reflected the lowest number of mortalities, ischemic strokes, major bleeding, non-major bleeding, and haemorrhagic stroke compared to apixaban and rivaroxaban. The sensitivity analysis consistently reflected cost savings, with the ischeamic stroke events having the biggest impact. Accounting for the Dutch situation, both scenarios showed total savings ranging from €45 to €229 million over 3 years. Conclusions: Switching eligible AF-patients from reduced-dose apixaban or rivaroxaban to lower-dose dabigatran has the potential to reduce healthcare payer’s budget expenditures and provide health gains. Cost savings can potentially be further enhanced by market share adjustments and further price reductions.

Future Innovations in Novel Detection for Atrial Fibrillation (FIND-AF): pilot study of an electronic health record machine learning algorithm-guided intervention to identify undiagnosed atrial fibrillation

IntroductionAtrial fibrillation (AF) is associated with a fivefold increased risk of stroke. Oral anticoagulation reduces the risk of stroke, but AF is elusive. A machine learning algorithm (Future Innovations in...

463 Adherence to Extended Venous Thromboembolism Prophylaxis for Post Operative Resection of Colorectal Malignancies

Abstract Aim Patients undergoing cancer resection abdominal surgery are at high risk of developing venous thrombo-embolism (VTE) in the post-operative period. To reduce this risk, these patients should be considered for extended pharmacological VTE prophylaxis for 28 days post-surgery as per NICE guidelines (NICE NG89). In our surgical department, we give all colorectal cancer resection patients 5000 units of Deltaparin for 28 days post resection unless it is contraindicated. We aimed to evaluate adherence to this guideline. Method This is a single-centre retrospective audit study. We included 100 colorectal cancer resection cases between 1st October 2021 and 28th February 2022 (n = 100). Retrospective data was collected including the type of procedure, histology and whether post-operative Deltaparin was prescribed for 28 days. All consecutive colorectal cancer resections were included in the study. The data was collected from the patient electronic records, electronic prescribing system and the electronic discharge summaries. Results The most common operation was anterior resection of the rectum (42%) followed by right hemicolectomy (40%). The Adherence to the NICE guidelines for extended VTE prophylaxis was 87%. Conclusions The adherence to the NICE guidelines in our department falls below the national target of 90% adherence. To improve the compliance, we will carry out staff education on appropriate anticoagulation prescribing and also display informative posters in the surgical wards to increase the awareness. We will aim to re-audit the adherence to the guidelines after implementing these measures.