Oral Anticoagulant Prescription Research Articles

Contemporary management of atrial fibrillation in primary and secondary care in the UK: the prospective long-term AF-GEN-UK Registry.

This study established a prospective registry of contemporary management of UK patients with atrial fibrillation (AF) by cardiologists, general practitioners, and stroke, acute, and emergency medicine physicians at baseline and 1-year follow-up. Data on patients with recently diagnosed AF (≤12 months) were collected from medical records from 101 UK sites to permit comparison of patient characteristics and treatments between specialities. The impact of guideline-adherent oral anticoagulation (OAC) use on outcomes was assessed using Cox regression analysis. One thousand five hundred and ninety-five AF patients [mean (standard deviation) age 70.5 (11.2) years; 60.1% male; 97.4% white] were recruited in June 2017-June 2018 and followed up for 1 year. Overall OAC prescription rates were 84.2% at baseline and 87.1% at 1 year, with non-vitamin K antagonist oral anticoagulants (NOACs) predominating (74.9 and 79.2% at baseline and 1 year, respectively). Vitamin K antagonist prescription was significantly higher in primary care, with NOAC prescription higher among stroke physicians. Guideline-adherent OAC (CHA2DS2-VASc ≥2) at baseline significantly reduced risk of death and stroke at 1 year [adjusted hazard ratio (95% confidence interval): 0.48 (0.27-0.84) and 0.11 (0.02-0.48), respectively]. Rhythm control is evident in ∼25%; only 1.6% received catheter ablation. High OAC use (>80%, mainly NOACs) rates varied by speciality, with VKA prescription higher in primary care. Guideline-adherent OAC therapy at baseline was associated with significant reduction in death and stroke at 1 year, regardless of speciality. Rhythm-control management is evident in only one-quarter despite AF symptoms reported in 56.6%. This registry extends the knowledge of contemporary AF management outside cardiology and demonstrates good implementation of clinical guidelines for the management of AF, particularly for stroke prevention.

Association of Oral Anticoagulation Prescription with Clinical Events in Patients with an Asymptomatic Unrepaired Abdominal Aortic Aneurysm.

Background: Most abdominal aortic aneurysms (AAA) have large volumes of intraluminal thrombus which has been implicated in promoting the risk of major adverse events. The aim of this study was to examine the association of therapeutic anticoagulation with AAA-related events and major adverse cardiovascular events (MACE) in patients with an unrepaired AAA. Methods: Patients with an asymptomatic unrepaired AAA were recruited from four sites in Australia. The primary outcome was the combined incidence of AAA repair or AAA rupture-related mortality (AAA-related events). The main secondary outcome was MACE (the combined incidence of myocardial infarction, stroke, or cardiovascular death). The associations of anticoagulation with these outcomes were assessed using Cox proportional hazard analyses (reporting hazard ratio, HR, and 95% confidence intervals, CI) to adjust for other risk factors. Results: A total of 1161 patients were followed for a mean (standard deviation) of 4.9 (4.0) years. Of them, 536 (46.2%) patients had a least one AAA-related event and 319 (27.5%) at least one MACE. In the sample, 98 (8.4%) patients were receiving long-term therapeutic anticoagulation using warfarin (84), apixaban (7), rivaroxaban (6), or dabigatran (1). Prescription of an anticoagulant was associated with a reduced risk of an AAA-related event (adjusted HR 0.61; 95% CI 0.42, 0.90, p = 0.013), but not MACE (HR 1.16; 95% CI 0.78, 1.72, p = 0.476). Conclusions: These findings suggest that AAA-related events but not MACE may be reduced in patients prescribed an anticoagulant medication. Due to the inherent biases of observational studies, a randomized controlled trial is needed to assess whether anticoagulation reduces the risk of AAA-related events.

Concurrent Use of Oral Anticoagulants and Sulfonylureas in Individuals With Type 2 Diabetes and Risk of Hypoglycemia: A UK Population-Based Cohort Study.

ObjectiveTo investigate the association of concurrent use of oral anticoagulants (OACs) and sulfonylureas and the risk of hypoglycemia in individuals with type 2 diabetes mellitus (T2DM).Research Design and MethodsA retrospective cohort study was conducted between 2001 and 2017 using electronic primary healthcare data from the IQVIA Medical Research Data (IMRD) that incorporates data supplied by The Health Improvement Network (THIN), a propriety database of Cegedim SA. Individuals with T2DM who received OAC prescription and sulfonylureas were included. We compared the risk of hypoglycemia with sulfonylureas and OACs using propensity score matching and Cox regression.Results109,040 individuals using warfarin and sulfonylureas and 77,296 using direct oral anticoagulants (DOACs) and sulfonylureas were identified and included. There were 285 hypoglycemia events in the warfarin with sulfonylureas group (incidence rate = 17.8 per 1,000 person-years), while in the sulfonylureas only, 304 hypoglycemia events were observed (incidence rate = 14.4 per 1,000 person-years). There were 14 hypoglycemic events in the DOACs with sulfonylureas group (incidence rates = 14.8 per 1,000 person-years), while in the sulfonylureas alone group, 60 hypoglycemia events were observed (incidence rate =23.7 per 1,000 person-years). Concurrent use of warfarin and sulfonylureas was associated with increased risk of hypoglycemia compared with sulfonylureas alone (HR 1.38; 95% CI 1.10–1.75). However, we found no evidence of an association between concurrent use of DOACs and sulfonylureas and risk of hypoglycemia (HR 0.54; 95% CI, 0.27–1.10) when compared with sulfonylureas only.ConclusionsWe provide real-world evidence of possible drug-drug interactions between warfarin and sulfonylureas. The decision to prescribe warfarin with coexistent sulfonylureas to individuals with T2DM should be carefully evaluated in the context of other risk factors of hypoglycemia, and availability of alternative medications.

Direct Oral Anticoagulants in Old and Frail Patients with Atrial Fibrillation: The Advantages of an Anticoagulation Service.

Despite the recent advancements, oral anticoagulation is still challenging in some patients and this is the case for old and frail patients. The large majority of frail patients with atrial fibrillation should receive anticoagulation since the associated benefits outweigh the risk of bleeding. A multidisciplinary consensus document on the use and prescription of direct oral anticoagulants (DOACs) in older and frail patients with atrial fibrillation has been recently published. In this manuscript we provide a comment on this document and add insights into the management of these patients. The new DOAC age had imposed a paradigm shift in the management of patients with the need for clinically-oriented services rather than laboratory-oriented services. In this paper we provide tools for a structured patient-oriented DOACs treatment service supported by a multidisciplinary approach.

Geographic and temporal variation in the treatment and outcomes of atrial fibrillation: a population-based analysis of national quality indicators.

Background:Assessment of potential geographic variation in quality indicators of atrial fibrillation care may identify opportunities for improvement in the quality of atrial fibrillation care. The objective of this study was to assess for potential geographic variation in the quality of atrial fibrillation care in Alberta, Canada.Methods:In a population-based cohort of adults (age ≥ 18 yr) with incident nonvalvular atrial fibrillation (NVAF) diagnosed between Apr. 1, 2008, and Mar. 31, 2016, in Alberta, we investigated the variation in national quality indicators of atrial fibrillation care developed by the Canadian Cardiovascular Society. Specifically, we assessed the geographic and temporal variation in the proportion of patients with initiation of oral anticoagulant therapy, persistence with therapy, ischemic stroke and major bleeding outcomes 1 year after atrial fibrillation diagnosis using linked administrative data sets. We defined stroke risk using the CHADS2 score. We assessed geographic variation using small-area variation statistics and geospatial data analysis.Results:Of the 64 093 patients in the study cohort (35 019 men [54.6%] and 29 074 women [45.4%] with a mean age of 69 [standard deviation 15.9] yr), 36 199 were at high risk for stroke and 14 411 were at moderate risk. Within 1 year of NVAF diagnosis, 20 180 patients (55.7%) in the high-risk group and 6448 patients (44.7%) in the moderate-risk group were prescribed anticoagulation. A total of 2187 patients (3.4%) had an ischemic stroke, and 2996 patients (4.7%) experienced a major bleed. There was substantial regional variation observed in initiation of oral anticoagulant therapy but not in the proportion of patients with ischemic stroke or major bleeding. Among the 64 Health Status Areas in Alberta, therapy initiation rates ranged from 22.6% to 71.2% among patients at high stroke risk and from 22.7% to 55.8% among those at moderate stroke risk, with clustering of lower therapy initiation rates in rural northern regions.Interpretation:The rate of initiation of oral anticoagulant therapy among adults with incident atrial fibrillation was less than 60% in patients in whom oral anticoagulant therapy would be considered guideline-appropriate care. The large geographic variation in oral anticoagulant prescribing warrants additional study into patient, provider and health care system factors that contribute to variation and drive disparities in high-quality, equitable atrial fibrillation care.

Anticoagulation for atrial fibrillation in people with serious mental illness in the general hospital setting

ObjectivePeople with serious mental illnesses (SMI) have an increased risk of stroke compared to the general population. This study aims to evaluate oral anticoagulation prescription trends in atrial fibrillation (AF) patients with and without a comorbid SMI. MethodsAn open-source retrieval system for clinical data (CogStack) was used to identify a cohort of AF patients with SMI who ever had an inpatient admission to King's College Hospital from 2011 to 2020. A Natural Language Processing pipeline was used to calculate CHA2DS2-VASc and HASBLED risk scores from Electronic Health Records free text. Antithrombotic prescriptions of warfarin and Direct acting oral anti-coagulants (DOACs) (apixaban, rivaroxaban, dabigatran, edoxaban) were extracted from discharge summaries. ResultsAmong patients included in the study (n = 16 916), 2.7% had a recorded co-morbid SMI diagnosis. Compared to non-SMI patients, those with SMI had significantly higher CHA2DS2-VASc (mean (SD): 5.3 (1.96) vs 4.7 (2.08), p < 0.001) and HASBLED scores (mean (SD): 3.2 (1.27) vs 2.5 (1.29), p < 0.001). Among AF patients having a CHA2DS2-VASc ≥2, those with co-morbid SMI were less likely than non-SMI patients to be prescribed an OAC (44% vs 54%, p < 0.001). However, there was no evidence of a significant difference between the two groups since 2019. ConclusionOver recent years, DOAC prescription rates have increased among AF patients with SMI in acute hospitals. More research is needed to confirm whether the introduction of DOACs has reduced OAC treatment gaps in people with serious mental illness and to assess whether the use of DOACs has improved health outcomes in this population.

Non-VKA Oral Anticoagulants in Adult Congenital Heart Disease: a Single-Center Study.

Non-VKA oral anticoagulants (NOACs) prescription is increasing in adults with congenital heart disease (ACHD). However, data on efficacy and safety in ACHD is unclear, particularly in severe CHD. The study aimed to review the safety and efficacy of NOACs in ACHD. Retrospective evaluation of ACHD patients started on NOACs from 2014 to 2020, with the primary endpoints of bleeding or thromboembolic events (TE). CHA2DS2-VASc and HAS-BLED scores were calculated, mortality was assessed, and risk factors for bleeding were identified. A total of 93 patients were included, the mean age was 52 ± 15years, 58% were female, 55.9% had moderate CHD, and 23.7% had severe CHD (3.2% Fontan). Most (66%) had a CHA2DS2-VASc score ≥ 2 and 82% HAS-BLED ≤ 2. In a median follow-up of 41 (IQR 21) months (400.4 patient-years), there were TE in two patients. The annual risk for TE was 0.49%/patient/year. The cardiovascular mortality was 2% and all-cause mortality 5%; there were no fatal TE or bleeding events. Minor (n = 6, 6.5%) and major (n = 3, 3.2%) bleeding events were observed, a median of 12 (IQR 15) months after starting NOAC therapy. The annual risk for bleeding was 2.2%/patient/year. Renal disease (HR 14.6 [95% CI 1.23-73.6], p = 0.033) and the HAS-BLED score were predictors of major (adjusted HR 6.97 [95% CI 1.69-28.78], p = 0.007) and minor (adjusted HR 3.80 [95% CI 1.48-9.78], p = 0.006) bleeding complications. In this real-life cohort of selected ACHD, the use of NOACs was safe and effective, with a low incidence of bleeding events.

Incidence of nonvalvular atrial fibrillation and oral anticoagulant prescribing in England, 2009 to 2019: A cohort study.

BackgroundAtrial fibrillation (AF) is an important risk factor for ischaemic stroke, and AF incidence is expected to increase. Guidelines recommend using oral anticoagulants (OACs) to prevent the development of stroke. However, studies have reported the frequent underuse of OACs in AF patients. The objective of this study is to describe nonvalvular atrial fibrillation (NVAF) incidence in England and assess the clinical and socioeconomic factors associated with the underprescribing of OACs.Methods and findingsWe conducted a population-based retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD) database to identify patients with NVAF aged ≥18 years and registered in English general practices between 2009 and 2019. Annual incidence rate of NVAF by age, deprivation quintile, and region was estimated. OAC prescribing status was explored for patients at risk for stroke and classified into the following: OAC, aspirin only, or no treatment. We used a multivariable multinomial logistic regression model to estimate relative risk ratios (RRRs) and 95% confidence intervals (CIs) of the factors associated with OAC or aspirin-only prescribing compared to no treatment in patients with NVAF who are recommended to take OAC. The multivariable regression was adjusted for age, sex, comorbidities, socioeconomic status, baseline treatment, frailty, bleeding risk factors, and takes into account clustering by general practice. Between 2009 and 2019, 12,517,191 patients met the criteria for being at risk of developing NVAF. After a median follow-up of 4.6 years, 192,265 patients had an incident NVAF contributing a total of 647,876 person-years (PYR) of follow-up. The overall age-adjusted incidence of NVAF per 10,000 PYR increased from 20.8 (95% CI: 20.4; 21.1) in 2009 to 25.5 (25.1; 25.9) in 2019. Higher incidence rates were observed for older ages and males. Among NVAF patients eligible for anticoagulation, OAC prescribing rose from 59.8% (95% CI: 59.0; 60.6) in 2009 to 83.2% (95% CI: 83.0; 83.4) in 2019. Several conditions were associated with lower risk of OAC prescribing: dementia [RRR 0.52 (0.47; 0.59)], liver disease 0.58 (0.50; 0.67), malignancy 0.74 (0.72; 0.77), and history of falls 0.82 (0.78; 0.85). Compared to white ethnicity, patients from black and other ethnic minorities were less likely to receive OAC; 0.78 (0.65; 0.94) and 0.76 (0.64; 0.91), respectively. Patients living in the most deprived areas were less likely to receive OAC 0.85 (0.79; 0.91) than patients living in the least deprived areas. Practices located in the East of England were associated with higher risk of prescribing aspirin only over no treatment than practices in London (RRR 1.22; 95% CI 1.02 to 1.45). The main limitation of this study is that these findings depends on accurate recording of conditions by health professionals and the inevitable residual confounding due to lack of data on certain factors that could be associated with under-prescribing of OACs.ConclusionsThe incidence of NVAF increased between 2009 and 2015, before plateauing. Underprescribing of OACs in NVAF is associated with a range of comorbidities, ethnicity, and socioeconomic factors, demonstrating the need for initiatives to reduce inequalities in the care for AF patients.

Frailty and oral anticoagulant prescription in adults with atrial fibrillation: A systematic review.

The objectives of this study were to determine the prevalence of frailty in the context of atrial fibrillation (AF); to identify the most commonly used frailty instruments in AF; and to describe the effect of frailty on non-vitamin K oral anticoagulant (NOAC) prescription for stroke prevention in adults with AF. A systematic search of databases, including Medline, Embase, Web of Science, Cochrane Library, Scopus, and CINAHL, was conducted using search terms including "atrial fibrillation," "frailty," and "anticoagulation." A narrative synthesis was undertaken. A total of 92 articles were screened, and 12 articles were included. The mean age of the participants (n=212,111) was 82 years (range=77-85 years) with 56% of participants identified as frail and 44% identified non-frail. A total of five different frailty instruments were identified: the Frailty Phenotype (FP; n=5, 42%), the Clinical Frailty Scale (CFS; n=4, 33%), Cumulative Deficit Model of Frailty (CDM; n=1, 8%), Edmonton Frail Scale (n=1, 8%) and the Resident Assessment Instrument - Minimum Data Set (RAI-MDS 2.0; n=1, 8%). Frailty was identified as an important barrier to anticoagulant therapy with 52% of the frail population anticoagulated vs 67% non-frail. Frailty is an important consideration in anticoagulation decision making for stroke prevention in patients with AF. There is scope to improve frailty screening and treatment. Frailty status is an important risk marker and should be considered when evaluating stroke risk alongside congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism, vascular disease, age 65-74 years, sex category (CHA2DS2-VASc) and Hypertension, Abnormal renal/liver function, Stroke, Bleeding, Labile, Elderly, and Drugs (HAS-BLED) scores.

Documentation of atrial fibrillation among non-conveyed ambulance patients: a new primary prevention opportunity?

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is a significant risk factor for stroke. Prescription of oral anticoagulant (OAC) medication reduces the risk of AF-related stroke by 64% - yet over 400,000 people in England have undiagnosed (and therefore untreated) AF.Emergency medical services (EMS) encounter a wide range of patients, some of whom may not engage with other healthcare services. AF may be detected by EMS in connection with the cause of the call, or as an incidental finding. While EMS are not traditionally utilised for public health screening, they may offer an opportunity to identify patients with undiagnosed or untreated AF and refer onward.This study aimed to explore what proportion of patients seen by EMS who were not transported to hospital had AF and to estimate how many would potentially benefit from OAC. A retrospective service evaluation was conducted using routinely collected data from a large UK regional ambulance service. The sample included adults attended by EMS on the 15th of each month in 2019, who were not transported to hospital and where an electrocardiogram was recorded. Of those with AF, we calculated the proportion in whom this was possibly new and report whether OAC was prescribed. There were 859 patients who met the inclusion criteria, of whom 91 (11%) had AF documented. Of the 91 patients with AF, 23 (25%) had no documented history of AF or OAC prescription, so were potentially new diagnoses of AF, who would benefit from consideration of OAC therapy. The EMS assessment offers an opportunity for AF to be identified in patients who were not transported to hospital. EMS may have a role in primary prevention of harm, including stroke, by identifying and referring patients with AF for consideration of OAC.

Effect of Mailing Educational Material to Patients With Atrial Fibrillation and Their Clinicians on Use of Oral Anticoagulants

Only about half of patients with atrial fibrillation (AF) who are at increased risk for stroke are treated with an oral anticoagulant (OAC), despite guideline recommendations for their use. Educating patients with AF about prevention of stroke with OACs may enable them as agents of change to initiate OAC treatment. To determine whether an educational intervention directed to patients and their clinicians stimulates the use of OACs in patients with AF who are not receiving OACs. The Implementation of a Randomized Controlled Trial to Improve Treatment With Oral Anticoagulants in Patients With Atrial Fibrillation (IMPACT-AFib) trial was a prospective, multicenter, open-label, pragmatic randomized clinical trial conducted from September 25, 2017, to May 1, 2019, embedded in health plans that participate in the US Food and Drug Administration's Sentinel System. It used the distributed database comprising health plan members to identify eligible patients, their clinicians, and outcomes. IMPACT-AFib enrolled patients with AF, a CHA2DS2-VASc (cardiac failure or dysfunction, hypertension, age 65-74 [1 point] or ≥75 years [2 points], diabetes, and stroke, transient ischemic attack or thromboembolism [2 points]-vascular disease, and sex category [female]) score of 2 or more, no evidence of OAC prescription dispensing in the preceding 12 months, and no hospitalization-related bleeding event within the prior 6 months. Randomization to a single mailing of patient and/or clinician educational materials vs control. Analysis was performed on a modified intention-to-treat basis. The primary end point was the proportion of patients with at least 1 OAC prescription dispensed or at least 4 international normalized ratio test results within 1 year of the intervention. Among 47 333 patients, there were 24 909 men (52.6%), the mean (SD) age was 77.9 (9.7) years, mean (SD) CHA2DS2-VASc score was 4.5 (1.7), 22 404 patients (47.3%) had an ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) bleeding risk score of 5 or more, and 8890 patients (18.8%) had a history of hospitalization for bleeding. There were 2328 of 23 546 patients (9.9%) in the intervention group with initiation of OAC at 1 year compared with 2330 of 23 787 patients (9.8%) in the control group (adjusted OR, 1.01 [95% CI, 0.95-1.07]; P = .79). Among a large population with AF with a guideline indication for OACs for stroke prevention who were randomized to a mailed educational intervention or to usual care, there was no clinically meaningful, numerical, or statistically significant difference in rates of OAC initiation. More-intensive interventions are needed to try and address the public health issue of underuse of anticoagulation for stroke prevention among patients with AF. ClinicalTrials.gov Identifier: NCT03259373.

Oral anticoagulants in older patients with atrial fibrillation: insights from a nationwide study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Bayer Background Atrial fibrillation (AF) is a predominant risk factor of ischemic stroke and prophylactic treatment with oral anticoagulants (OACs) is recommended in older patients. Advancing age increases the risk of stroke, however, ageing simultaneously increases the prevalence of bleeding risk factors such as multimorbidity, polypharmacy, frail vessels as well as the tendency to fall. As such, treatment with OACs in older frail patients is often associated with complex risk-benefit considerations. Purpose To examine treatment patterns with OACs in older patients with AF. Methods Using nationwide registries and databases, Danish patients &amp;gt; 75 years of age with a primary diagnosis of AF between 2010 and 2018 were identified. The primary event of interest was claimed prescriptions for OACs in a period of 180 days after hospital contact due to AF. Proportions of patients treated with OACs were estimated and depicted graphically. Clinical factors associated with the probability of receiving OAC treatment were identified using adjusted logistic regression models with estimates presented as Odds Ratios (OR) with 95% Confidence Intervals (95% CI). Results A total of 40,027 patients were included with a slight majority of women (54%). The median age was 81 years (IQR 78-86). We found that an overall 32,235 patients (81%) were prescribed an OAC after hospital contact due to AF. Increasing age was associated with a clear tendency toward a decreased probability of receiving OAC treatment. As such, among patients aged 75 years, 85 % received OAC treatment decreasing to 68 % in patients aged 90 years. (Figure 1) Collectively during the study period, a substantial increase in the proportion of patients treated with OACs was observed. Hence, in 2011, 63 % claimed OAC prescriptions whereas this proportion increased to 92 % in 2018. (Figure 2) Factors related to a low probability of OAC treatment were bleeding risk factors such as a history of bleeding (OR 0.58, 95% CI 0.53-0.82), hemorrhagic stroke (OR 0.21, 95% CI 0.16-0.27), treatment with dual antiplatelet therapy (OR 0.52, 95% CI 0.47-0.59) as well as markers of frailty such as osteoporosis (OR 0.78, 95% CI 0.71-0.85) and previous falling (OR 0.56, 95 % CI 0.51-0.62). Conclusions In this large nationwide study, we found that in older patients with AF, the overall rates of OAC prescription were relatively high (~ 80%) but decreased notably with age. Factors associated with not receiving guideline directed OAC treatment were generally related to bleeding risk factors or frailty. These data highlight a clinical conundrum as older patients potentially benefit the most from treatment with OACs. Figure legend Figure 1 Combined plot depicting the absolute number of patients by age (red bars) as well as the proportion of patients treated with oral anticoagulants by age (blue curve). Figure 2 Plot depicting the proportion of patients receiving treatment with oral anticoagulants by calendar year.

C67A BLITZ-AF CANCER REGISTRY: BASELINE CHARACTERISTICS OF PATIENTS WITH ATRIAL FIBRILLATION AND CANCER

Abstract Background Evidences on atrial fibrillation (AF) in patients with cancer are limited, specifically with respect to antithrombotic therapy. Methods BLITZ-AF Cancer is a prospective, non-interventional study of the epidemiology and management of AF in patients with cancer. Patients were included from 112 cardiology units in Italy, Belgium, Netherlands, Spain, Portugal, and Ireland, based on the following criteria: age ≥18 years; documented cancer other than basal-cell or squamous-cell carcinoma of the skin diagnosed within 3 years; electrocardiographically confirmed AF within 1 year; no concomitant interventional study. Follow-up is ongoing. Results From June 26th, 2019 to Sep. 30th, 2021, 1,514 subjects were enrolled. The most frequent cancer locations were lung (14.9%), colorectal (14.1%), breast (13.9%), prostate (8.8%), and non-Hodgkin lymphoma (8.1%); 463 (30.6%) of participants had metastases. AF was first-detected in 323 (21.3%), paroxysmal in 460 (30.4%), persistent in 192 (12.7%), long-standing persistent in 33 (2.2%), and permanent in 506 (33.4%); 590 (39.0%) patients had symptoms attributable to AF. Baseline characteristics are presented in the Table. Males were more than women and almost half of the subjects was &amp;gt;75 years-old. Cardiovascular risk factors were common and approximately 31% had heart failure or coronary artery disease. Previous thromboembolic and haemorrhagic events had occurred in 14% and 10% of subjects, respectively. The median CHA2DS2VASc score was 3. As shown in the Figure, the prescription of oral anticoagulants, especially direct-acting ones (DOACs), rose after the cardiology assessment, while the percentage of participants without any antithrombotic therapy declined. Among 1,427 patients with non-valvular AF (i.e., no mitral stenosis or prosthetic mechanical valve), 997 (69.9%) were prescribed on DOACs at discharge/after consultation. At multivariable logistic regression analysis, variables associated with DOAC use were female sex (OR 1.58, 95% CI 1.22-2.05), age (OR 2.00, 95% CI 1.39-2.88 and OR 2.63, 95%CI 1.84-3.76, respectively, for 65-74 years and ≥75 years vs &amp;lt;65 years), hypertension (OR 1.43, 95%CI 1.10-1.87), long-standing persistent or permanent AF (OR 1.36, 95%CI 1.05-1.78). Haemoglobin &amp;lt;12 g/dL (OR 0.57, 95%CI 0.45-0.73), and planned cancer treatment (OR 0.72, 95%CI 0.57-0.92) were independently associated with a lower prescription of DOACs. Conclusions BLITZ-AF Cancer provides extensive information on a large, contemporary cohort of individuals with AF and cancer. This baseline snapshot indicates that cardiologists pursue the implementation of DOACs in these patients, although residual use of other antithrombotic therapies or lack of any thrombo-prophylaxis remains substantial.

Temporal Trends in Oral Anticoagulant Prescription in Atrial Fibrillation Patients between 2004 and 2019.

Background: In the recent years, antithrombotic prophylaxis in patients with atrial fibrillation (AF) has changed significantly. The main aim of this study is to assess the temporal trends of antithrombotic therapy and identify factors predisposing oral anticoagulant (OAC) use in stroke prevention in AF patients. Methods: The present study is a retrospective, observational, single-center study, which includes consecutively hospitalized patients in the reference cardiology center from January 2004 to December 2019. Results: A total of 9656 patients (43.7% female, mean age 71.2 years) with AF between 2004–2019 are included. Among the total study population, in most of the patients (81.1%), OAC therapy was used, antiplatelet (APT) therapy was prescribed for 13.5% patients, heparins for 2.1% patients and 3.3% of patients did not receive any stroke prevention. OAC prescription significantly increased from 61.6% in 2004 to 97.4% in 2019. The independent predictors of OAC prescription were: the period of hospitalization, non-paroxysmal AF, age, hypertension, diabetes mellitus, previous thromboembolism, hospitalization due to electrical cardioversion, ablation or AF without any procedures. Conclusions: In hospitalized patients with AF, during sixteen years of the study period, a significant increase in OAC use and a decrease in APT use were noted. Factors other than these included in the CHA2DS2-VASc score were independent predictors of OAC use.

Abstract 73: Associations Of Social Determinants Of Health On Anticoagulation Treatment Among Patients With Atrial Fibrillation At Risk For Stroke At A Large Health System

Objectives: The objective of this study was to evaluate anticoagulant prescribing disparities in atrial fibrillation (AF) by exploring associations between social determinants of health (SDOH) collected from electronic health records (EHR) and oral anticoagulant (OAC) prescription. Methods: This retrospective study included adult patients newly diagnosed with AF who had ≥ 2 encounters from a large, integrated healthcare system between May 2016 and May 2021. Patient-level demographics, prescribing provider specialties, comorbidities, medications, and SDOH were extracted from EHRs. Area deprivation index (ADI) was linked to patient records as a measure of socioeconomic status. Patients were followed for 1 year from diagnosis. Multivariable logistic regression models were used to assess associations between SDOH, clinical factors, and OAC prescribing and class (warfarin or direct-acting OAC[DOAC]) of OAC prescribed. Results: Of 19,191 AF patients, 12,718 patients (66.3%) were prescribed an OAC within the first year of diagnosis. Mean age was 71.1 + 12.9 years, 43.9% (8,430 of 19,191) were females, and 91.2% (17,705 of 19,191) were white. Patients were less likely to be prescribed an OAC (relative risk [95% CI]) if they were widowed (0.98 [0.96-0.99] vs single) or had history of alcoholism (0.86 [0.79-0.95] vs no history). Most patients (53.3%) received prescriptions from a primary care provider. A linear relationship was found between worsening ADI and increased warfarin prescriptions compared with DOACs. Conclusion: Though guideline-concordant anticoagulation use remained suboptimal, clinical characteristics were strong predictors if an OAC was prescribed for AF stroke prevention. Worsening ADI was associated with an increased likelihood for patients to be prescribed warfarin instead of a DOAC.

Unequal prescription of anticoagulants among females and males with atrial fibrillation and similar stroke risk: Should we omit sex category from the CHA2DS2-VASc score?

The CHA2DS2-VASc stroke risk score has been recommended by the European Society of Cardiology atrial fibrillation (AF) guidelines to guide decision on oral anticoagulation (OAC) prescription in AF patients. Although female sex initially was considered an individual risk factor warranting antithrombotic treatment in all female AF patients independent of other risk factors, this recommendation was revised as growing evidence showed that, rather, female sex is a risk modifier, as sex does not contribute to stroke risk in the absence of other risk factors.

CE-539-02 UTILIZATION OF ORAL ANTICOAGULATION AFTER BLEEDING EVENTS IN STROKE PATIENTS WITH ATRIAL FIBRILLATION

Oral anticoagulation (OAC) is recommended for stroke prophylaxis after diagnosis of atrial fibrillation (AF). However, the optimal strategy or timing for continuing OAC use after bleeding events in these patients has not been well established. This analysis seeks to characterize real-world patterns of OAC utilization after bleeding events in patients with prior ischemic stroke and diagnosed AF. Patients with a diagnosis code for a bleeding event between 1/01/2007-3/31/2021 were identified in the U.S. de-identified Optum® Clinformatics® claims database. Bleed events were identified based on the presence of an ICD-9/-10 diagnosis code for bleeding in any site of service, and included: hemorrhagic stroke (HS), other intracranial hemorrhage (ICH), or extracranial hemorrhage (ECH). Patients were required to have any prior evidence of AF diagnosis, and must have OAC prescription coverage within the 3 months prior to the index bleed event. Kaplan-Meier curves were created to estimate the rate at which OACs were restarted after index for each bleed type, including all available follow-up time in the database for each patient. A total of 44,207 patients were identified: 7,755 patients with HS, 781 with ICH, and 35,671 with ECH. After HS, an estimated 26% of patients resumed OAC early, within 30 days of the bleed event; 45% restarted later (36% between 30 days-1 year, 9% after 1 year), and the remaining 29% permanently discontinued. Overall, the median time to refill was 3.1 months. After an Other ICH event: 36% resumed early, 42% restarted later (36% within 1 year and 6% after 1 year), and 22% discontinued; median time to refill was 1.9 months. After ECH: 42% resumed early, 48% restarted later (40% within 1 year and 8% beyond 1 year), with 10% discontinuing; median time to refill was 1.4 months. Although the risk-benefit profile of OAC resumption after bleeding events in AF patients has not been definitively characterized to-date, our analysis of a large claims database indicates that resumption of OAC after bleeding is common in clinical practice, with 71%-90% of patients either continuing or restarting after a brief pause. Upcoming randomized trials aim to provide more information in this space and may enable development of a clearer clinical consensus.

Abstract 12: Oral Anticoagulant Prescribing For Older Adults Newly Diagnosed With Atrial Fibrillation During Hospitalization

Background: Oral anticoagulants are indicated in patients with atrial fibrillation (AF) at elevated thromboembolic risk. AF is often diagnosed during hospitalization, yet little is known about rates of anticoagulant initiation in this setting. Methods: We examined a 20% national sample of Medicare fee-for-service beneficiaries enrolled in Part D, aged &gt; 65 years, who were hospitalized in 2016, and who received a new diagnosis of AF. The primary outcome was anticoagulant claim within 7 days of discharge home. We used multivariable logistic regression and post-estimation predicted probabilities to identify predictors of discharge with an anticoagulant, hypothesizing that thromboembolic risk, bleeding risk, and frailty would independently influence anticoagulant initiation. Results: Among 31,889 patients diagnosed with AF while hospitalized (mean age, 78; 52% female; 84% white; 95% CHA 2 DS 2 -VASc ≥2; 84% HAS-BLED ≥2; 37% frail), one-quarter initiated an anticoagulant following discharge. In multivariable models, rates of anticoagulant initiation varied by primary reason for hospitalization, with the highest predicted probability of initiation among those with a primary diagnosis of AF (46.3%; 95% CI 45.1-47.5), followed by cardiac surgery (42.8%; 39.6-46.0), other cardiovascular conditions (25.1%; 24.3-26.0), non-cardiac diagnoses (18.6%; 17.3-19.9), and bleeds (3.6%; 2.3-5.0). Higher CHA 2 DS 2 -VASc score was associated with a small increase in anticoagulant initiation (predicted probability 19.8% [15.4-24.2] for CHA 2 DS 2 -VASc &lt;2 and 25.2% [24.7-25.7] for ≥4). Higher HAS-BLED score was associated with a small decrease (25.7% [24.6-26.8] for HAS-BLED &lt;2 and 23.4% [22.7-24.1] for ≥3). Increased frailty was associated with decreased likelihood of anticoagulant initiation, with robust and moderately-severely frail patients having predicted probabilities of 25.0% (23.3-26.6) and 17.6% (15.9-19.2) respectively. Discussion: Anticoagulant initiation is uncommon among older adults newly diagnosed with AF during hospitalization, even among those hospitalized primarily for AF and those with high thromboembolic risk. Providers should carefully weigh risks and benefits of anticoagulants with all inpatients found to have AF.

Prescription of oral anticoagulation in geriatric patients with atrial fibrillation

Prescription of oral anticoagulation in geriatric patients with atrial fibrillation

Safety of direct oral anticoagulants (DOACs) vs. warfarin for people aged ≥ 75 years with atrial fibrillation: a cohort study

Abstract Introduction Warfarin significantly reduces the risk of stroke in people with atrial fibrillation (AF), but historically has been underused in older people due to complicated dosage regimens. DOACs offer an attractive alternative to warfarin and were shown to be non-inferior in randomised controlled trials, however older people were underrepresented in these trials and there have been few studies investigating outcomes specifically in this high risk group (1). Aim To compare the risk of major, non-major, gastrointestinal, and intracranial bleeding between warfarin and DOACs in people aged ≥ 75 years with AF. Methods A cohort of patients aged ≥ 75 years with a diagnosis of AF was extracted from the Clinical Practice Research Datalink (CPRD). Patients could enter the study on the date of their first prescription for warfarin or a DOAC between 1/1/2013 and 27/12/2017. Patients were censored on the date of the outcome, death, or leaving the general practice. Switching between anticoagulants and unexposed periods were measured using prescription mapping. Crude and adjusted hazard rates of the risk of bleeding were calculated using a Cox proportional hazards model with oral anticoagulant prescribing as a time varying covariate. Results The cohort included 10,149 patients in the warfarin group and 10,237 in the DOAC group. The groups had similar characteristics and the average age was 81 in the warfarin group and 82 in the DOAC group. The table summarises the results. Whilst major and non-major bleeding was similar between all DOACs and warfarin, rivaroxaban was associated with higher risk and apixaban lower risk when analysed separately. Risk of gastrointestinal bleeding was higher with all DOACs and rivaroxaban than warfarin but apixaban was not significantly different. Few intracranial events occurred (n=131). Conclusion The results indicate that DOACs as a group are not significantly different to warfarin, however when analysed separately, apixaban may be safer. While the study relies on prescription data and hence it is not known if patients were taking the medications, the large cohort studied is representative of older people who are prescribed these medications in UK primary care. Reference (1) Mitchell A, Watson MC, Welsh T, McGrogan A. Effectiveness and safety of direct oral anticoagulants versus vitamin K antagonists for people aged 75 years and over with atrial fibrillation: A systematic review and meta-analyses of observational studies. Journal of Clinical Medicine. 2019; 8 (554).