Influence of Direct Oral Anticoagulants on Rates of Oral Anticoagulation for Atrial Fibrillation

• Published in: Journal of the American College of Cardiology Vol. 69; no. 20; pp. 2475 - 2484
• Main Authors: Marzec, Lucas N., Wang, Jingyan, Shah, Nilay D., Chan, Paul S., Ting, Henry H., Gosch, Kensey L., Hsu, Jonathan C., Maddox, Thomas M.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 23.05.2017; Elsevier Limited
• Subjects: Administration, Oral; Aged; Anticoagulants; Anticoagulants - classification; Anticoagulants - therapeutic use; Antithrombins - therapeutic use; atrial fibrillation; Atrial Fibrillation - complications; Atrial Fibrillation - drug therapy; Atrial Fibrillation - epidemiology; Cardiac arrhythmia; Cardiology; Cardiovascular; Cardiovascular disease; Clinical outcomes; direct oral anticoagulants; Drug therapy; Female; Fibrillation; Health Services Accessibility - trends; Humans; Male; Medication Therapy Management - organization & administration; Medication Therapy Management - standards; Middle Aged; Needs Assessment; oral anticoagulation; Patients; Practice Patterns, Physicians' - statistics & numerical data; Practice Patterns, Physicians' - trends; Quality Improvement; Registries; Stroke - etiology; Stroke - prevention & control; United States - epidemiology; Warfarin; Warfarin - therapeutic use; United States > US; direct oral anticoagulants; OR; AF; CI; CAD; NCDR; DOAC; TIA; OAC; MOR; atrial fibrillation; PAD; oral anticoagulation; coronary artery disease; mean odds ratio; peripheral arterial disease; transient ischemic attack; odds ratio; direct oral anticoagulant; National Cardiovascular Data Registry; confidence interval
• ISSN: 0735-1097; 1558-3597; 1558-3597
• DOI: 10.1016/j.jacc.2017.03.540

Oral anticoagulation (OAC) with warfarin is underused for atrial fibrillation (AF). The availability of direct oral anticoagulants (DOACs) may improve overall OAC rates in AF patients, but a large-scale evaluation of their effects has not been conducted. This study assessed the effect of DOAC availability on overall OAC rates for nonvalvular AF. Between April 1, 2008 and September 30, 2014, we identified 655,000 patients with nonvalvular AF and a CHA2DS2-VASc score of >1 in the National Cardiovascular Data Registry PINNACLE registry. Temporal trends in overall OAC and individual warfarin and DOAC use were analyzed. Multivariable hierarchical logistic regression identified patient factors associated with OAC and DOAC use. Practice variation of OAC and DOAC use was also assessed. Overall OAC rates increased from 52.4% to 60.7% among eligible AF patients (p for trend <0.01). Warfarin use decreased from 52.4% to 34.8% (p for trend <0.01), and DOAC use increased from 0% to 25.8% (p for trend <0.01). An increasing CHA2DS2-VASc score was associated with higher OAC use (odds ratio [OR]: 1.06; 95% confidence interval [CI]: 1.05 to 1.07), but with lower DOAC use (OR: 0.97; 95% CI: 0.96 to 0.98). Significant practice variation was present in OAC use (median odds ratio [MOR]: 1.52; 95% CI: 1.45 to 1.57) and in DOAC use (MOR: 3.58; 95% CI: 3.05 to 4.13). Introduction of DOACs in routine practice was associated with improved rates of overall OAC use for AF, but significant gaps remain. In addition, there is significant practice-level variation in OAC and DOAC use. [Display omitted]