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Romiti GF, Corica B, Pipitone E, Vitolo M, Raparelli V, Basili S, Boriani G, Harari S, Lip GYH, Proietti M. Prevalence, management and impact of chronic obstructive pulmonary disease in atrial fibrillation: a systematic review and meta-analysis of 4,200,000 patients. Eur Heart J 2021; 42:3541-3554. [PMID: 34333599 DOI: 10.1093/eurheartj/ehab453] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/07/2021] [Accepted: 06/29/2021] [Indexed: 11/12/2022] Open
Abstract
AIM Prevalence of chronic obstructive pulmonary disease (COPD) in atrial fibrillation (AF) patients is unclear, and its association with adverse outcomes is often overlooked. Our aim was to estimate the prevalence of COPD, its impact on clinical management and outcomes in patients with AF, and the impact of beta-blockers (BBs) on outcomes in patients with COPD. METHODS AND RESULTS A systematic review and meta-analysis was conducted according to international guidelines. All studies reporting the prevalence of COPD in AF patients were included. Data on comorbidities, BBs and oral anticoagulant prescription, and outcomes (all-cause death, cardiovascular (CV) death, ischaemic stroke, major bleeding) were compared according to COPD and BB status. Among 46 studies, pooled prevalence of COPD was 13% [95% confidence intervals (CI) 10-16%, 95% prediction interval 2-47%]. COPD was associated with higher prevalence of comorbidities, higher CHA2DS2-VASc score and lower BB prescription [odds ratio (OR) 0.77, 95% CI 0.61-0.98]. COPD was associated with higher risk of all-cause death (OR 2.22, 95% CI 1.93-2.55), CV death (OR 1.84, 95% CI 1.39-2.43), and major bleeding (OR 1.45, 95% CI 1.17-1.80); no significant differences in outcomes were observed according to BB use in AF patients with COPD. CONCLUSION COPD is common in AF, being found in 13% of patients, and is associated with increased burden of comorbidities, differential management, and worse outcomes, with more than a two-fold higher risk of all-cause death and increased risk of CV death and major bleeding. Therapy with BBs does not increase the risk of adverse outcomes in patients with AF and COPD.
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Affiliation(s)
- Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Bernadette Corica
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Eugenia Pipitone
- Ospedale Regionale "Beata Vergine", Via Turconi 23, 6850 Mendrisio, Switzerland
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, via Giuseppe Campi 287, 41125, Modena, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Brownlow Hill, L69 7TX Liverpool, UK.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, via Giuseppe Campi 287, 41125 Modena, Italy
| | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, Via Luigi Borsari, 46, 44121 Italy.,University of Alberta, Faculty of Nursing, 11405-87 Avenue, T6G 1C9 Edmonton, Alberta, Canada
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza-University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, via Giuseppe Campi 287, 41125, Modena, Italy
| | - Sergio Harari
- U.O. di Pneumologia e Terapia Semi-Intensiva Respiratoria-Servizio di Fisiopatologia Respiratoria ed Emodinamica Polmonare, Ospedale San Giuseppe-MultiMedica IRCCS, Via San Vittore 12, 20123 Milan, Italy.,Department of Medical Sciences, San Giuseppe Hospital MultiMedica IRCCS, Via San Vittore 12, 20123 Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Via della Commenda 19, 20122 Milan, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Brownlow Hill, L69 7TX Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
| | - Marco Proietti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Brownlow Hill, L69 7TX Liverpool, UK.,Department of Clinical Sciences and Community Health, University of Milan, Via della Commenda 19, 20122 Milan, Italy.,Geriatric Unit, IRCCS Istituti Clinici Scientifici Maugeri, Via Camaldoli 64, Milano 20138, Italy
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Silva Pinto S, Teixeira A, Henriques TS, Monteiro H, Martins C. AF-React study: atrial fibrillation management strategies in clinical practice-retrospective longitudinal study from real-world data in Northern Portugal. BMJ Open 2021; 11:e040404. [PMID: 33782016 PMCID: PMC8009225 DOI: 10.1136/bmjopen-2020-040404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To determine the prevalence of atrial fibrillation (AF) and to assess how these patients are being cared for: what anticoagulants are being prescribed and are they being prescribed as recommended? DESIGN Retrospective longitudinal study. SETTING This study was conducted in the Regional Health Administration of Northern Portugal. PARTICIPANTS This study used a database that included 63526 patients with code K78 of the International Classification of Primary Care between January 2016 and December 2018. RESULTS The prevalence of AF among adults over 40 years in the northern region of Portugal was 2.3% in 2016, 2.8% in 2017 and 3% in 2018. From a total of 63 526 patients, 95.8% had an indication to receive anticoagulation therapy. Of these, 44 326 (72.9%) are being treated with anticoagulants: 17 936 (40.5%) were prescribed vitamin K antagonists (VKAs) and 26 390 (59.5%) were prescribed non-VKA anticoagulants. On the other hand, 2688 patients of the total (4.2%) had no indication to receive anticoagulation therapy. Of these 2688 patients, 1100 (40.9%) were receiving anticoagulants. CONCLUSIONS The prevalence of AF is 3%. Here, we report evidence of both undertreatment and overtreatment. Although having an indication, a considerable proportion of patients (27.1%) are not anticoagulated, and among patients with AF without an indication to receive anticoagulation therapy, a considerable proportion (40.9%) are receiving anticoagulants. The AF-React study brings extremely relevant conclusions to Portugal and follows real-world studies in patients with AF in Europe, presenting some data not yet studied.
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Affiliation(s)
- Susana Silva Pinto
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine of the University of Porto, Porto, Portugal
- Health Centre Grouping Santo Tirso/Trofa, Family Health Unit S. Tomé, Santo Tirso, Portugal
| | - Andreia Teixeira
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine of the University of Porto, Porto, Portugal
- Instituto Politécnico de Viana do Castelo, Viana do Castelo, Portugal
| | - Teresa S Henriques
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Hugo Monteiro
- Research and Planning Department, Regional Health Administration of Northern, Ministry of Health Portugal, Porto, Portugal
| | - Carlos Martins
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine of the University of Porto, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine of the University of Porto, Porto, Portugal
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3
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Liu J, Wang Y, Guo W, Cheng Y, Zhang S, Wu B, Liu M. Temporal trends of atrial fibrillation and/or rheumatic heart disease-related ischemic stroke, and anticoagulant use in Chinese population: An 8-year study. Int J Cardiol 2020; 322:258-264. [PMID: 32814110 DOI: 10.1016/j.ijcard.2020.08.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/22/2020] [Accepted: 08/10/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE Underuse of anticoagulants in ischemic stroke patients with atrial fibrillation (AF) and/or rheumatic heart disease (RHD) is a global concern, especially in China. However, the extent to which anticoagulants are underused in AF and/or RHD-related ischemic stroke in China has not been well characterized. We aimed to explore the temporal trends of AF and/or RHD-related ischemic stroke patients, anticoagulation use and factors related to suboptimal use of anticoagulants in a Chinese population. METHODS Acute ischemic stroke patients admitted to department of neurology, West China hospital, Sichuan university were included from January 1st 2010 to December 31st 2017. Temporal trends of AF and RHD related ischemic strokes were compared over 2 year epochs (2010-2011, 2012-2013, 2014-2015 and 2016-2017). Multivariable logistic regression models were performed to evaluate the variables associated with non-anticoagulants at discharge. RESULTS Of 4357 acute ischemic stroke patients (≤7 days after onset) included between 2010 and 2017, 823(18.9%) were AF and/or RHD-related. Over the 8 years, the proportion of RHD-ischemic stroke decreased significantly from 7.8% in 2010-2011 to 4.5% in 2016-2017, whereas no reduction in AF-ischemic stroke was observed. There was an increase in the proportion of AF and/or RHD patients who were prescribed anticoagulants at discharge (from 26.4% to 45.1%, P for trend<0.001), while the proportion given antiplatelet therapy decreased with time (from 56.0% to 30.0%, P for trend<0.001). The use of non-vitamin K antagonist oral anticoagulants (NOAC) use at discharge remained low during the study period (2.1%).Older age (per 5 years increase, OR 1.91, 95% CI 1.28-2.86), higher NIHSS score on admission(OR 1.08, 95% CI 1.05-1.11), the presence of non-symptomatic hemorrhagic transformation(OR 2.54, 95% CI 1.67-3.94) and symptomatic hemorrhagic transformation(OR 3.04, 95% CI 1.14-9.73) were independently associated with non-anticoagulant use at discharge. However, patients with a prior diagnosis of AF/RHD and anticoagulation before admission were more likely to receive anticoagulants at discharge. CONCLUSIONS In an ischemic stroke population in China we found an increasing but still low use of anticoagulation. Further research is required on how to improve anticoagulation use at discharge in ischemic stroke patients, including access to NOAC's.
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Affiliation(s)
- Junfeng Liu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yanan Wang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Wen Guo
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yajun Cheng
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Shihong Zhang
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Bo Wu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China
| | - Ming Liu
- Center of Cerebrovascular Diseases, Department of Neurology, West China Hospital, Sichuan University, Chengdu, PR China.
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Wändell P, Forslund T, Danin Mankowitz H, Ugarph-Morawski A, Eliasson S, Braunschwieg F, Holmström M. Venous thromboembolism 2011-2018 in Stockholm: a demographic study. J Thromb Thrombolysis 2020; 48:668-673. [PMID: 31578660 PMCID: PMC6800867 DOI: 10.1007/s11239-019-01966-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Venous thromboembolism (VTE) is an important cause of morbidity and mortality in Western countries. The incidence rate of VTE is estimated at 1-2 cases per 1000 annually. This study was a population-based cohort study of previously treatment naïve patients with a first occurrence of venous thromboembolism (VTE), using data from the administrative health data register of the Stockholm Region 2011-2018. Data on anticoagulant treatment was taken from the Swedish Prescribed Drug Register. We also analyzed all VTE events between 2011 and 2018. Altogether 14,849 naïve incident VTE cases were identified. In 2011 the majority of patients with a first episode of VTE were prescribed warfarin versus non-vitamin K antagonist oral anticoagulants (NOACs), 1144 versus 5. In contrast in 2018, the majority of patients were treated with NOACs, 1049 versus 59 treated with warfarin. Treatment with low molecular weight heparin only decreased from 814 to 683 patients. The frequency of all VTE events in the population increased over time from 1.88/1000 to 1.93/1000 (p = 0.072), and PE diagnoses increased from 0.69/1000 to 0.76/1000 (p = 0.003). In conclusion, during 2011-2018 there has been a shift of prescription of warfarin to a clear predominance of NOACs in the treatment of VTE in the Stockholm Region, in line with current recommendations. In the clinical situation, treatment has been simplified as monitoring of warfarin has decreased substantially. PE events increased during the time period in the population even if the increase was rather modest, while all VTE events did not increase significantly.
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Affiliation(s)
- Per Wändell
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden. .,Division of Family Medicine and Primary Care, NVS Department, Karolinska Institutet, Alfred Nobels Allé 23 (D2), 141 83, Huddinge, Sweden.
| | - Tomas Forslund
- Department of Medicine, Centre for Pharmacoepidemiology, Karolinska Institutet, Solna, Sweden.,Public Healthcare Services Committee, Department of Healthcare Development, Region Stockholm, Stockholm, Sweden
| | - Helene Danin Mankowitz
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden
| | - Anna Ugarph-Morawski
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Huddinge, Sweden.,Academic Primary Care Centre, Region Stockholm, Stockholm, Sweden
| | - Staffan Eliasson
- Department of Medicine, Karolinska Institutet, Solna, Sweden.,Themes Heart and Vascular, Karolinska University Hospital, Solna, Sweden
| | - Frieder Braunschwieg
- Department of Medicine, Karolinska Institutet, Solna, Sweden.,Themes Heart and Vascular, Karolinska University Hospital, Solna, Sweden
| | - Margareta Holmström
- Department of Medicine, Karolinska Institutet, Solna, Sweden.,Team Coagulation Disorders, Karolinska University Hospital, Solna, Sweden
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Ehrlinder H, Orsini N, Modig K, Hofman-Bang C, Wallén H, Gigante B. Clinical characteristics and antithrombotic prescription in elderly hospitalized atrial fibrillation patients: A cross-sectional analysis of a Swedish single-center clinical cohort. IJC HEART & VASCULATURE 2020; 27:100505. [PMID: 32258363 PMCID: PMC7114891 DOI: 10.1016/j.ijcha.2020.100505] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 02/27/2020] [Accepted: 03/18/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Antithrombotic treatment represents a dilemma in elderly patients with atrial fibrillation since both risk of thromboembolism and bleeding are age-dependent complications. A paradigm shift occurred over the past 10 years when aspirin was overcome by warfarin and further by the direct oral anticoagulants. Here we present a clinical practice-based analysis of a cohort of elderly inpatient atrial fibrillation patients and investigate the influence of clinical factors in the choice of antithrombotic strategy. METHODS Study participants (n = 2943) are consecutive patients aged 75-104 years discharged from a Swedish university hospital with atrial fibrillation or atrial flutter as main diagnosis between November 1st 2010 and December 31st 2017. Cardiovascular risk factors, comorbidities and antithrombotic treatment at discharge were manually extracted from medical charts. A logistic regression analysis was performed to estimate predictors of the probability to receive direct oral anticoagulants (DOACs) compared to warfarin. RESULTS Patients aged ≥90 y (n = 446, women 73%) showed the highest prevalence of cardiovascular comorbidities and the highest bleeding and thromboembolic risk. DOACs became more commonly prescribed than warfarin in 2016/2017 across all ages. However, the probability to receive DOAC as compared to warfarin was lower in the presence of high bleeding risk (OR 0,55; 95% CI 0,40-0,77; p = 0,00) and high thromboembolic risk (OR 0,74; 95% CI 0,59-0,94; p = 0,01). CONCLUSION Elderly atrial fibrillation patients represent a heterogenous group where the oldest (≥90 years) show both a very high thromboembolic and bleeding risk profile. In the presence of high thromboembolic and bleeding risk, warfarin was still preferred over DOAC.
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Affiliation(s)
- Hanne Ehrlinder
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Nicola Orsini
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Karin Modig
- Unit of Epidemiology. Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Claes Hofman-Bang
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Bruna Gigante
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Cardiovascular Medicine Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
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Kjerpeseth LJ, Selmer R, Ariansen I, Karlstad Ø, Ellekjær H, Skovlund E. Comparative effectiveness of warfarin, dabigatran, rivaroxaban and apixaban in non-valvular atrial fibrillation: A nationwide pharmacoepidemiological study. PLoS One 2019; 14:e0221500. [PMID: 31449560 PMCID: PMC6709911 DOI: 10.1371/journal.pone.0221500] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 08/09/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To compare effectiveness and safety of warfarin and the direct oral anticoagulants (DOAC) dabigatran, rivaroxaban and apixaban in non-valvular atrial fibrillation in routine care. METHODS From nationwide registries, we identified treatment-naïve patients initiating warfarin, dabigatran, rivaroxaban or apixaban for non-valvular atrial fibrillation from July 2013 to December 2015 in Norway. We assessed prescription duration using reverse waiting time distribution. Adjusting for confounding in a Cox proportional hazards model, we estimated one-year risks for ischemic stroke, transient ischemic attack (TIA) or systemic embolism, major or clinically relevant non-major bleeding; intracranial; gastrointestinal; and other bleeding. We censored at switch of treatment or 365 days of follow-up. RESULTS We included 30,820 treatment-naïve patients. Compared to warfarin, the adjusted hazard ratios (HR) for ischemic stroke, TIA or systemic embolism were 0.96 (95% CI 0.71-1.28) for dabigatran, 1.12 (95% CI 0.87-1.45) for rivaroxaban and 0.97 (95% CI 0.75-1.26) for apixaban. Corresponding hazard ratios for major or clinically relevant non-major bleeding were 0.73 (95% CI 0.62-0.86) for dabigatran, 0.97 (95% CI 0.84-1.12) for rivaroxaban and 0.71 (95% CI 0.62-0.82) for apixaban. Statistically significant differences of other safety outcomes compared to warfarin were fewer intracranial bleedings with dabigatran (HR 0.28, 95% CI 0.14-0.56), rivaroxaban (HR 0.40, 95% CI 0.23-0.69) and apixaban (HR 0.56, 95% CI 0.34-0.92); fewer gastrointestinal bleedings with apixaban (HR 0.70, 95% CI 0.52-0.93); and fewer other bleedings with dabigatran (HR 0.67, 95% CI 0.55-0.81) and apixaban (HR 0.70, 95% CI 0.59-0.83). CONCLUSION After 1 year follow-up in treatment-naïve patients initiating oral anticoagulation for non-valvular atrial fibrillation, all DOACs were similarly effective as warfarin in prevention of ischemic stroke, TIA or systemic embolism. Safety from bleedings was similar or better, including fewer intracranial bleedings with all direct oral anticoagulants, fewer gastrointestinal bleedings with apixaban and fewer other bleedings with dabigatran and apixaban.
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Affiliation(s)
- Lars J. Kjerpeseth
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
- * E-mail:
| | - Randi Selmer
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Inger Ariansen
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Øystein Karlstad
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Stroke Unit, Department of Internal Medicine, St. Olav’s Hospital, Trondheim, Norway
| | - Eva Skovlund
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Chronic Diseases and Ageing, Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
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Maura G, Billionnet C, Drouin J, Weill A, Neumann A, Pariente A. Oral anticoagulation therapy use in patients with atrial fibrillation after the introduction of non-vitamin K antagonist oral anticoagulants: findings from the French healthcare databases, 2011-2016. BMJ Open 2019; 9:e026645. [PMID: 31005934 PMCID: PMC6500377 DOI: 10.1136/bmjopen-2018-026645] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES To describe (i) the trend in oral anticoagulant (OAC) use following the introduction of non-vitamin K antagonist oral anticoagulant (NOAC) therapy for stroke prevention in atrial fibrillation (AF) patients and (ii) the current patterns of use of NOAC therapy in new users with AF in France. DESIGN (i) Repeated cross-sectional study and (ii) population-based cohort study. SETTING French national healthcare databases (50 million beneficiaries). PARTICIPANTS (i) Patients with identified AF in 2011, 2013 and 2016 and (ii) patients with AF initiating OAC therapy in 2015-2016. PRIMARY AND SECONDARY OUTCOME MEASURES: (i) Trend in OAC therapy use in patients with AF and (ii) patterns of use of NOAC therapy in new users with AF. RESULTS Between 2011 and 2016, use of OAC therapy moderately increased (+16%), while use of antiplatelet therapy decreased (-22%) among all patients with identified AF. In 2016, among the 1.1 million AF patients, 66% used OAC therapy and were more likely to be treated by vitamin K antagonist (VKA) than NOAC therapy, including patients at higher risk of stroke (63.5%), while 33% used antiplatelet therapy. Among 192 851 new users of OAC therapy in 2015-2016 with identified AF, NOAC therapy (66.3%) was initiated more frequently than VKA therapy, including in patients at higher risk of stroke (57.8%). Reduced doses were prescribed in 40% of NOAC new users. Several situations of inappropriate use at NOAC initiation were identified, including concomitant use of drugs increasing the risk of bleeding (one in three new users) and potential NOAC underdosing. CONCLUSIONS OAC therapy use in patients with AF remains suboptimal 4 years after the introduction of NOACs for stroke prevention in France and improvement in appropriate prescribing regarding NOAC initiation is needed. However, NOAC therapy is now the preferred drug class for initiation of OAC therapy in patients with AF, including in patients at higher risk of stroke.
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Affiliation(s)
- Géric Maura
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology - UMR 1219, Bordeaux, France
| | - Cécile Billionnet
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Jérôme Drouin
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Alain Weill
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Anke Neumann
- Department of Studies in Public Health, French National Health Insurance (Caisse Nationale de l’Assurance Maladie/Cnam), Paris, France
| | - Antoine Pariente
- University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology - UMR 1219, Bordeaux, France
- CHU Bordeaux, Bordeaux, France
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Guo J, Guan T, Fan S, Chao B, Wang L, Liu Y. Underuse of Oral Anticoagulants in Patients With Ischemic Stroke and Atrial Fibrillation in China. Am J Cardiol 2018; 122:2055-2061. [PMID: 30292336 DOI: 10.1016/j.amjcard.2018.08.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 01/27/2023]
Abstract
Anticoagulant therapy is an effective stroke prevention measurement for subjects with atrial fibrillation (AF) who are at high risk of ischemic stroke. However, it is reported that oral anticoagulants (OACs) are generally underused in clinical practice. A better awareness of current usage of anticoagulant therapy would enable prevention of stroke secondary to AF. Therefore, we determined the nationwide prevalence of AF and the frequency of OACs use among patients with ischemic stroke in China. Based on the China National Stroke Screening Survey, a representative nationwide sample of 1,252,703 adults over 40 years old during 2013 and 2014 was involved. Information on demographic data, diagnosis of stroke, behavioral risk factors, family history of stroke, related diseases, and medications was collected. The community-based survey data showed that 5,588 patients (12.0%) with ischemic stroke had previous, or newly diagnosed, AF. Therefore, more than 2.15 million ischemic stroke patients had AF in China. Among ischemic stroke patients with AF, the strongest risk factor was coronary heart disease (odds ratio = 2.53), whereas dyslipidemia accounted for the largest contribution (population-attributable risk proportion = 17.33%). Of ischemic stroke patients with AF, only 2.2% had taken OACs; of them, 98.2% had taken warfarin. In conclusion, a large number of ischemic stroke patients with AF are significantly undertreated with OACs in China. This highlights the need for improvement of prevention of ischemic stroke secondary to AF.
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9
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Risk factors for stroke and choice of oral anticoagulant in atrial fibrillation. Eur J Clin Pharmacol 2018; 74:1653-1662. [PMID: 30116828 DOI: 10.1007/s00228-018-2540-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 08/08/2018] [Indexed: 12/18/2022]
Abstract
PURPOSE To investigate risk factors for stroke in patients initiating oral anticoagulants for atrial fibrillation in Norway and their association with receiving DOACs versus warfarin. METHODS From nationwide registries, we identified naïve users initiating treatment with warfarin, dabigatran, rivaroxaban, or apixaban for atrial fibrillation from 2010 to 2015 in Norway. We studied temporal changes in the CHA2DS2-VASc score and its component risk factors. We used multiple logistic regressions to identify CHA2DS2-VASc risk factors associated with receiving DOACs versus warfarin in 2015. RESULTS From 2010 to 2015, the yearly number of new oral anticoagulant users increased from 7588 to 13,344. All new users initiated warfarin in 2010, while 86% initiated a DOAC in 2015. The mean CHA2DS2-VASc score decreased from 3.2 (SD 1.7) to 3.1 (SD 1.6) in the same period. Vascular disease (0.56 [0.49-0.63]), congestive heart failure (OR 0.65 [95% CI 0.58-0.72]), and diabetes (0.83 [0.73-0.95]) decreased the odds of receiving DOACs instead of warfarin, and ischemic stroke/transient ischemic attack/arterial thromboembolism (1.31 [1.12-1.54]), age 65-74 (1.23 [1.06-1.43]), and female sex (1.22 [1.10-1.36]) increased it. Age ≥ 75 (reference age < 65) and hypertension had no impact. CONCLUSIONS The uptake of DOACs was rapid and spurred an increase in new users of oral anticoagulants for atrial fibrillation from 2010 to 2015 in Norway. The mean CHA2DS2-VASc score did not change substantially during this period. Vascular disease, heart failure, and diabetes were associated with initiation of warfarin, and previous stroke, age 65-74 and female sex with initiation of DOACs.
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The safety and efficacy of non-vitamin K antagonist oral anticoagulants in atrial fibrillation in the elderly. Int J Cardiol 2018; 265:118-124. [DOI: 10.1016/j.ijcard.2018.02.066] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/28/2018] [Accepted: 02/16/2018] [Indexed: 01/27/2023]
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Zhu J, Alexander GC, Nazarian S, Segal JB, Wu AW. Trends and Variation in Oral Anticoagulant Choice in Patients with Atrial Fibrillation, 2010-2017. Pharmacotherapy 2018; 38:907-920. [PMID: 29920705 DOI: 10.1002/phar.2158] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Since 2010, several non-vitamin K antagonist oral anticoagulants (NOACs) have been brought to the U.S. market, yet little is known regarding their evolving adoption for prophylaxis of atrial fibrillation (AF)-related stroke. We examined temporal trends in choice of oral anticoagulants (OACs) among incident OAC users with AF and its association with patient demographic and clinical characteristics. METHODS We conducted a serial cross-sectional analysis of medical and pharmacy claims for commercial and Medicare Advantage enrollees in a large, private, U.S. health plan. We identified 112,187 adults with nonvalvular AF starting OACs between October 2010 and March 2017. Multivariable logistic regression was used to examine the associations of patient characteristics with prescription of NOACs versus warfarin. Multinomial logistic regression was used to test the associations of patient characteristics with choice among NOACs. RESULTS The prescription of NOACs has increased dramatically since their introduction in October 2010. In the first quarter of 2017 (2017Q1), 7502 patients started OACs, of whom 78.9% used NOACs and 21.1% warfarin. For NOACs, 3.8% used dabigatran, 25.0% rivaroxaban, and 50.1% apixaban. In multivariable analyses, factors associated with choice of NOACs versus warfarin included younger age, lower stroke or bleeding risk, fewer comorbidities, higher education level or household net worth, and prescription by cardiologists (all p<0.001). There was no sex difference in likelihood of filling NOACs versus warfarin in 2010Q4-2012, but women had higher odds of starting NOACs (odds ratio = 1.19; 95% confidence interval = 1.14-1.25) in 2015-2017Q1. Among NOAC users, the odds of apixaban prescription increased with age, female sex, stroke or bleeding risk, and comorbidities (all p<0.05). CONCLUSION NOAC prescriptions have increased substantially among incident OAC users with nonvalvular AF, predominantly driven by increased prescription of apixaban. Warfarin and apixaban were generally preferred for elderly patients, patients with higher stroke or bleeding risk, and patients with more comorbidities.
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Affiliation(s)
- Junya Zhu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,OptumLabs, Cambridge, Massachusetts
| | - G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Saman Nazarian
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.,The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jodi B Segal
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Albert W Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
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Diaz H, Bagheri H, Palmaro A, Rousseau V, Bourrel R, Montastruc JL, Birebent J. Patterns of direct oral anticoagulant drug prescription in France in 2010–2013: a study in the Midi-Pyrénées area. Eur J Clin Pharmacol 2018; 74:945-951. [DOI: 10.1007/s00228-018-2449-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 03/14/2018] [Indexed: 01/24/2023]
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Hellfritzsch M, Rasmussen L, Hallas J, Pottegård A. Using the Symmetry Analysis Design to Screen for Adverse Effects of Non-vitamin K Antagonist Oral Anticoagulants. Drug Saf 2018; 41:685-695. [DOI: 10.1007/s40264-018-0650-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Pottegård A, Grove EL, Hellfritzsch M. Use of direct oral anticoagulants in the first year after market entry of edoxaban: A Danish nationwide drug utilization study. Pharmacoepidemiol Drug Saf 2017; 27:174-181. [DOI: 10.1002/pds.4350] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 10/02/2017] [Accepted: 10/10/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public Health; University of Southern Denmark; Odense Denmark
| | - Erik L. Grove
- Department of Cardiology; Aarhus University Hospital; Aarhus Denmark
- Department of of Clinical Medicine, Faculty of Health; Aarhus University; Aarhus Denmark
| | - Maja Hellfritzsch
- Clinical Pharmacology and Pharmacy, Department of Public Health; University of Southern Denmark; Odense Denmark
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