scholarly journals Prescription of oral anticoagulants and antiplatelets for stroke prophylaxis in atrial fibrillation: nationwide time series ecological analysis

EP Europace ◽  
2020 ◽  
Vol 22 (9) ◽  
pp. 1311-1319 ◽  
Author(s):  
Jianhua Wu ◽  
Eman S Alsaeed ◽  
James Barrett ◽  
Marlous Hall ◽  
Campbell Cowan ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Temporal Trends ◽  
Antiplatelet Agents ◽  
The Elderly ◽  
Early Years ◽  
Prescription Data ◽  
Ecological Analysis ◽  
General Practices

Abstract Aims To investigate trends in the prescription of oral anticoagulants (OACs) and antiplatelet agents for atrial fibrillation (AF). Methods and results Prescription data for 450 518 patients with AF from 3352 General Practices in England, was obtained from the GRASP-AF registry, 2009–2018. Annualized temporal trends for OAC and antiplatelet prescription were reported according to eligibility based on stroke risk (CHADS2 or CHA2DS2-VASc scores ≥1 or >2, respectively). From 2009 to 2018, the prevalence of AF increased from 1.6% [95% confidence interval (CI) 1.5–1.7%] to 2.4% (2.3–2.5%), and for those with AF the proportion prescribed OAC increased from 47.6% to 75.0% (P-trend < 0.001; relative risk 1.57, 95% CI 1.55–1.60) and for antiplatelet decreased from 37.4% to 9.2% (P-trend < 0.001). In early-years (2009–2013), eligible patients aged ≥80 years were less likely to be prescribed OAC than patients aged <80 years [odds ratio (OR) 0.55, 95% CI 0.51–0.59 for CHADS2≥1 in 2009] (all P-trends < 0.001). This ‘OAC prescription gap’ reduced over the study period (OR 0.93, 0.90–0.96 in 2018). Whilst the prescription of direct oral anticoagulant (DOAC) as a proportion of all OAC increased from 0.1% (95% CI 0.0–0.2%) in 2011 to 58.8% (58.4–59.2%) in 2018, it was inversely associated with patient age (P-trend < 0.001) and their risk of stroke. Conclusion Between 2009 and 2018, in England, the use of OAC for stroke prophylaxis in AF increased, with DOAC accounting for over half of OAC uptake in 2018. Despite a reduction in the OAC-prescription gap, a new paradox exists relating to DOAC prescription for the elderly and those at higher risk of stroke.

The NOACs in special situations: the elderly, renal impairment, combination with antiplatelet agents and thrombolytics

ESC CardioMed ◽  
2018 ◽  
pp. 273-278
Author(s):  
Felicita Andreotti ◽  
Eliano Pio Navarese ◽  
Filippo Crea
Keyword(s):  
Atrial Fibrillation ◽  
Ischaemic Stroke ◽  
Acute Ischaemic Stroke ◽  
Oral Anticoagulants ◽  
Factor Xa ◽  
Antiplatelet Agents ◽  
Clinical History ◽  
The Elderly ◽  
Arterial Disease ◽  
Baseline Risk

Phase III randomised trials indicate that the non-vitamin K antagonist oral anticoagulants (NOACs) are preferable to warfarin in elderly, non-valvular atrial fibrillation patients, given a lower incidence of intracranial haemorrhage, a favourable overall efficacy and safety profile, and the lack of routine monitoring, although care is needed to dose-adjust for kidney function and to prevent gastrointestinal bleeds, depending on the NOAC. Advanced age should not exclude the use of any NOAC. Overall, NOACs perform well, relative to warfarin or aspirin, irrespective of renal function. However, all NOACs undergo variable renal clearance, and in Europe a creatinine clearance of less than 30 mL/min contraindicates dabigatran and less than 15 mL/min the factor Xa inhibitors. Trial outcomes stratified by antiplatelet therapy, after adjustment for baseline risk, show that concomitant antiplatelet use does not significantly alter the overall treatment effects of NOACs versus warfarin. Whether adding an antiplatelet to a NOAC in atrial fibrillation patients with arterial disease is beneficial requires randomized controlled testing. Current guidelines recommend that patients effectively anticoagulated with a NOAC who develop an acute ischaemic stroke should not be considered for thrombolysis unless clinical history or laboratory tests indicate low or no anticoagulation or at least two half-lives have elapsed from the last NOAC dose. Retrospective data suggest no prohibitive adverse events among selected NOAC-treated patients with acute ischaemic stroke receiving thrombolysis. Further investigation in this setting is warranted.

scholarly journals Utilization of Anticoagulants in Nonvalvular Atrial Fibrillation Before and After Catheter Ablation at Shanghai, China

2019 ◽  
Vol 25 ◽  
pp. 107602961982626
Author(s):  
Chen Tingting ◽  
Wang Yuzhu ◽  
Zhang Lin ◽  
Li Ran ◽  
Li Jing ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Antithrombotic Therapy ◽  
Stroke Risk ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Utilization Rate ◽  
Prescription Data ◽  
Nonvalvular Atrial Fibrillation ◽  
Before And After

Both vitamin K antagonists (VKAs) and novel oral anticoagulants (NOACs) are effective for stroke prevention in nonvalvular atrial fibrillation (NVAF) patients. This study evaluated the utilization of VKA and NOACs in NVAF patients before and after catheter ablation in China. Prescription data were retrospectively collected between January 1, 2016, and December 31, 2016, including indication of use, dose, renal function, and risk assessment (CHA2DS2-VASc score and HAS-BLED score) in Zhongshan Hospital of Fudan University. Trends and factors associated with anticoagulants use before and after ablation were evaluated. A total of 475 patients with NVAF who received ablation were included in the analysis. Of all, 53.26% of them received antithrombotic therapy preablation. Warfarin was prescribed in 35.26%, with NOACs in 11.37%. Four hundred seventy-three patients received antithrombotic therapy (99.58%) postablation, 236 patients with NOACs (49.68%). CHA2DS2-VASc score, HAS-BLED score, hypertension, diabetes mellitus, and alcohol were independently associated with anticoagulant utilization before catheter ablation. The higher CHA2DS2-VASc score was associated with less frequent prescription of NOACs postablation. The preablation anticoagulation use was still inadequate in China, and CHA2DS2-VASc score was a significant factor influencing the preablation anticoagulant utilization. The utilization rate of NOACs increased significantly postablation, especially for dabigatran, which implied that more physicians prefer to prescribe NOACs for NVAF patients after ablation in our country and may be attributed to the aspects such as ease of NOAC use but also possibly the greater safety and efficacy. Furthermore, the physicians may reluctant to use NOACs for high stroke risk atrial fibrillation patients after catheter ablation.

scholarly journals Long-term persistence and adherence with non-vitamin K oral anticoagulants in patients with atrial fibrillation and their associations with stroke risk

2020 ◽  
Author(s):  
Joris J Komen ◽  
Eibert R Heerdink ◽  
Olaf H Klungel ◽  
Aukje K Mantel-Teeuwisse ◽  
Tomas Forslund ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Early Years ◽  
Poor Adherence ◽  
Healthcare Database ◽  
Persistence Rates

Abstract Aims Studies on adherence and persistence with non-vitamin K oral anticoagulant (NOAC) treatment have relied on data from the early years of NOAC availability. We aimed to study long-term adherence and persistence with NOACs and their association with stroke risk. Methods and results From the Stockholm Healthcare database, we included 21 028 atrial fibrillation patients claiming a first NOAC prescription from July 2011 until October 2018, with more than 1000 patients having more than 5 years of follow-up (median: 2.0, interquartile range: 1.0–3.2). Persistence rates, defined as continuing to claim NOAC prescriptions within a 90-day gap, decreased to 70% at the end of follow-up. However, 85% of the patients were treated at the end of the study due to reinitiations. Adherence, calculated as medication possession rate (MPR) in 3 and 6-month intervals among persistent users, remained stable at 90%, with 75% of patients having an MPR >95% throughout the study period. Using a case–control design, we calculated associations of persistence and adherence with stroke risk, adjusting for potential confounders. The outcome was a composite of ischaemic or unspecified stroke and transient ischaemic attack. Non-persistence and poor adherence were both associated with increased stroke risk [non-persistence adjusted odds ratio (aOR): 2.05; 95% confidence interval (CI): 1.49–2.82, 1% reduction MPR aOR: 1.03; CI: 1.01–1.05]. There was no association between non-persistence or poor adherence and the falsification endpoints; fractions and respiratory infections, indicating no ‘healthy-adherer’ effect. Conclusion Persistence rates decreased slowly over time, but persistent patients had high adherence rates. Both non-persistence and poor adherence were associated with an increased stroke risk.

Abstract 15651: The Burden of Nontreatment or Undertreatment Among Non-valvular Atrial Fibrillation Patients With Elevated Stroke Risk: A Systematic Literature Review of Real-world Evidence

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Manuela Di Fusco ◽  
Matthew Sussman ◽  
Geoffrey Barnes ◽  
Charles Tao ◽  
John A Gillespie ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Literature Review ◽  
Clinical Outcomes ◽  
Systematic Literature Review ◽  
Stroke Risk ◽  
Treatment Guidelines ◽  
Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
The Body ◽  
Cochrane Library

Introduction: Global treatment guidelines (e.g., AHA/ACC/HRS, ESC, JCS) recommend treatment with oral anticoagulants (OACs) for patients with non-valvular atrial fibrillation (NVAF) and an elevated stroke risk, defined by CHA 2 DS 2 -VASc score ≥2. However, not all patients with NVAF and an elevated stroke risk receive guideline-recommended therapy. A systematic literature review of observational studies was undertaken based on PRISMA guidelines to identify the body of evidence on untreated and undertreated NVAF among patients with elevated stroke risk, and assess its epidemiological and clinical burden. Methods: An extensive search of MEDLINE, GoogleScholar, the Cochrane Library, relevant conference proceedings, and health technology assessments (HTAs) was conducted for RWE studies. Studies published between 1/2010-4/2020 were included if they evaluated rates of nontreatment or undertreatment in NVAF. Nontreatment was defined as absence of OACs, while undertreatment was defined as treatment with only antiplatelet agents. Studies focusing on valvular AF were excluded. Results: Thirty-nine published studies (13 countries) met inclusion criteria. Rates of nontreatment for patients with elevated stroke risk ranged from 2.0%-51.1% (median: 23.3%), while rates of undertreatment ranged from 10.0%-45.1% (median: 34.6%). Few studies assessed the relationship between nontreatment or undertreatment and clinical outcomes in the evaluated population. Among US outpatients with NVAF and an elevated stroke risk, those undertreated had a higher likelihood of death (HR: 1.22; 95% CI: 1.05-1.41; p=.006) compared to patients treated with OACs. Also, in a separate US study of NVAF patients with varying levels of warfarin exposure, patients with no warfarin exposure had significantly higher rates of ischemic stroke than patients with low adherence (4.41 vs. 1.87 per 100 person-years, p<.001) or high adherence (4.41 vs. 0.72 per 100 person years, p<.001). Conclusion: Rates of nontreatment and undertreatment among NVAF patients with elevated stroke risk remain high and are associated with potentially preventable cardiovascular events and death. Strategies to increase rates of treatment may reduce adverse clinical outcomes.

scholarly journals Ten-Year Trends in the Use of Oral Anticoagulants in Australian General Practice Patients With Atrial Fibrillation

2021 ◽  
Vol 12 ◽  
Author(s):  
Woldesellassie M. Bezabhe ◽  
Luke R. Bereznicki ◽  
Jan Radford ◽  
Barbara C. Wimmer ◽  
Colin Curtain ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
General Practice ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Secondary Outcome ◽  
Cross Sectional ◽  
Australian General Practice ◽  
Risk Patients ◽  
General Practices ◽  
Direct Acting

Objective: Appropriate use of oral anticoagulants (OACs) reduces the risk of stroke in patients with atrial fibrillation (AF). The study characterized the prescribing of OACs in people with AF in the Australian primary care setting over 10 years.Design: Retrospective population study.Setting and Participants: We performed 10 sequential cross-sectional analyses of patients with a recorded diagnosis of AF between 2009 and 2018 using national general practice data. The proportion of patients with AF who were prescribed an OAC based on their stroke risk was examined.Primary and secondary outcomes: The primary outcome was the proportion of high stroke risk patients who were prescribed an OAC over a decade. The secondary outcome was variation in OAC prescribing among general practices.Results: The sample size of patients with AF ranged from 9,874 in 2009 to 41,751 in 2018. The proportion who were prescribed an OAC increased from 39.5% (95% CI 38.6–40.5%) in 2009 to 52.0% (95% CI 51.5–52.4%) in 2018 (p for trend &lt; 0.001). During this time, the proportion of patients with AF and high stroke risk who were prescribed an OAC rose from 41.7% (95% CI 40.7–42.8%) to 55.2% (95% CI 54.7–55.8%; p for trend &lt; 0.001) with the direct-acting oral anticoagulants accounting for over three-quarters of usage by 2018. There was substantial variation in OAC prescribing between general practices. In 2018, the proportion of moderate to high stroke risk patients who were prescribed an OAC was 38.6% (95% CI 37.2–40.1%) in the lowest practice site quintiles and 65.6% (95% CI 64.5–66.7%) in the highest practice site quintiles.Conclusions: Over the 10 years, OAC prescribing in high stroke risk patients with AF increased by one-third. There was considerable variation in OAC prescribing between general practices.

Abstract 223: Impact of Differences in Once- vs Twice-Daily Medications Adherence on the Risk of Bleed and Stroke in Non-Valvular Atrial Fibrillation: Analysis of Randomized Trials and Claims Data Sources

2017 ◽  
Vol 10 (suppl_3) ◽  
Author(s):  
Colleen A McHorney ◽  
Eric D Peterson ◽  
Mike Durkin ◽  
Veronica Ashton ◽  
François Laliberté ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Stroke Risk ◽  
Claims Data ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Once Daily ◽  
Cardiovascular Medications ◽  
One Year ◽  
The Impact ◽  
Similar Risk

Background: In non-valvular atrial fibrillation (NVAF) patients, those receiving once-daily (QD) versus twice-daily (BID) non vitamin-K antagonist oral anticoagulants (NOACs) may have better medication adherence. The impact on stroke and bleed risk is not known. Objective: To estimate the impact of adherence differences between QD vs BID therapies on bleed and stroke risks in NVAF patients. Methods: The relation between adherence (proportion of days covered [PDC]) for QD vs BID NOACs and one year bleed risk was modeled using claims data from Truven Health Analytics MarketScan databases (7/2012-10/2015). Next, the relation between adherence and bleeding was calibrated to match that seen in the placebo and NOAC arms of previous randomized controlled trials (RCTs). Finally, we used adherence rates for QD (PDC=0.849) and BID (PDC=0.738) cardiovascular medications from a meta-analysis (Coleman et al.). These rates were used in the calibrated model to estimate bleeds. An analogous method was applied to evaluate the impact of QD vs BID adherence on stroke risk. Results: The relation between PDC and risks of bleed and stroke was modeled using claims data (N=65,022) and calibrated using RCTs. In the calibrated model, compared with BID dosing, QD dosing was associated with 81 fewer strokes (34% reduction) and 14 more bleeds (6% more) per 10,000 patients/year (Figure). Conclusion: Among NVAF patients, better adherence to QD dosing was associated with a significantly lower stroke risk of QD but similar risk of bleed.

scholarly journals Use of Guidelines for Reducing Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: A Review From a Latin American Perspective

2017 ◽  
Vol 24 (1) ◽  
pp. 22-32 ◽  
Author(s):  
Carlos Cantú-Brito ◽  
Gisele Sampaio Silva ◽  
Sebastián F. Ameriso
Keyword(s):  
Atrial Fibrillation ◽  
Latin America ◽  
Latin American ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Evidence Based ◽  
Scoring Methods ◽  
Essential Components ◽  
Evidence Based Guidelines

Atrial fibrillation (AF) is a prominent risk factor for stroke and a leading cause of death and disability throughout Latin America. Contemporary evidence-based guidelines for the management of AF and stroke incorporate the use of practical and relatively simple scoring methods to estimate both stroke and bleeding risk, in order to assist in matching patients with appropriate interventions. This review examines consistencies and differences among guidelines for reducing stroke risk in patients with AF, assessing the role of user-friendly scoring methods to determine appropriate patients for anticoagulation and other treatment options. Current options include warfarin and direct oral anticoagulants such as dabigatran, rivaroxaban, apixaban, and edoxaban. These agents have been found to be superior or noninferior to standard vitamin K antagonist anticoagulation in large randomized trials. Potential benefits of these agents mainly include lower ischemic stroke rates, reduced intracranial bleeding, no need for regular monitoring, and fewer drug–drug and drug–food interactions. Expert opinions regarding clinical situations for which data are presently lacking, such as emergency bleeding and stroke in anticoagulated patients, are also provided. Enhanced attention and adherence to evidence-based guidelines are essential components for a strategy to reduce stroke morbidity and mortality across Latin America.

scholarly journals Problems of Cardioembolic Stroke Primary and Secondary Prevention in the Latvian Population / Kardioemboliska Cerebrāla Infarkta Primārās un Sekundārās Profilakses Problēmas Latvijā

2015 ◽  
Vol 69 (5) ◽  
pp. 199-204
Author(s):  
Kristaps Jurjāns ◽  
Santa Sabeļnikova ◽  
Evija Miglāne ◽  
Baiba Luriņa ◽  
Oskars Kalējs ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Secondary Prevention ◽  
Patient Group ◽  
Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
Cardioembolic Stroke ◽  
University Hospital ◽  
Primary And Secondary Prevention ◽  
Stroke Patients ◽  
Very High

Abstract Atrial fibrillation is one of major risk factors of cerebral infarction. The use of oral anticoagulants is the only evidence-based method of reducing the risk of cardioembolic accidents. The guidelines of oral anticoagulant admission and usage have been available since 2012. The results of this study show that of 550 stroke patients that were admitted to Pauls Stradiņš Clinical University Hospital, Rīga, Latvia, from 1 January 2014 until 1 July 2014, atrial fibrillation was diagnosed in 247 (45%) cases, and of these patients, only 8.5% used oral anticoagulants before the onset of stroke. Six months after discharge of 111 (44.9%) stroke survivors, five (4.5%) used no secondary prevention medication, 27 (24.3%) used antiplatelet agents, 54 (48.6%) warfarin, and 25 (22.5%) used target specific oral anticoagulants (TSOACs). The mortality rate was significantly higher in the patient group that used no secondary prevention medication or antiplatelet agents compared to the patient group that used oral anticoagulants. The use of oral anticoagulants for primary stroke prevention in Latvia is insufficient. The mortality of cardioembolic stroke in 180 days is very high - 40.4%. Secondary prevention is essential to prevent recurrent cardioembolic accidents.

Abstract W P339: Anticoagulation Remains Underutilized in the Management of Atrial Fibrillation: Results From the Edmonton Registry of Atrial Fibrillation and StrokE (ERASE) Study

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Ghazala Basir ◽  
Ashfaq Shuaib ◽  
Affan Tahir ◽  
Kasim Qureshi ◽  
Hasnain Zeeshan ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Antithrombotic Therapy ◽  
Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
Tertiary Hospital ◽  
Stroke Patients ◽  
Single Centre ◽  
Chads2 Score ◽  
Similar Frequency ◽  
Prior Stroke

Background: Since 2010, three novel oral anticoagulants (NOAC) have been approved and included in the guidelines as alternatives to warfarin for the prevention of stroke in patients with non-valvular atrial fibrillation (NVAF). Prior to the introduction of NOACs, studies showed that anticoagulation with warfarin in stroke patients with NVAF is suboptimal with as few as 40% anticoagulated and most subtherapeutic. The goal of this study is to examine anticoagulation usage in a contemporary prospective registry of TIA/stroke patients with NVAF and determine whether the introduction of NOACs has increased anticoagulation usage. Methods: This is an ongoing single centre observational study. Consecutive TIA/ischemic stroke admissions (2012-13) to a tertiary hospital in Edmonton, Canada with NVAF were enrolled. Data regarding demographic, clinical, antithrombotic treatment and laboratory parameters were collected in a prospectively maintained database. Those with previously diagnosed NVAF were included in the present analysis (149/181). Clinical characteristics were compared between patients on anticoagulants and those on other/no antithrombotic therapy. Results: The 149 included patients had a mean (SD) age of 78.7 (10.0) years. Male were 52.3% and 86.6% (129) had a preadmission CHADS2 score ≥2. At the time of TIA/stroke, 51% (76/149) were on an anticoagulant, 24.2% (36/149) on antiplatelet agents and 28.4% (37/149) were on no antithrombotic therapy. Of the 76 patients on anticoagulants, 81.6% were on warfarin and the remaining (18.4%) were on a NOAC. Only 31% of patients on warfarin had a therapeutic INR at the time of stroke. Patients not anticoagulated had a similar frequency of prior stroke (21% vs. 23%; p=0.80) but tended to have a lower CHADS2 score (p=0.082) than those anticoagulated. In patients with CHADS≥2, 47% were not on an anticoagulant. Conclusions: Despite therapeutic advances in the treatment of NVAF, anticoagulation usage in TIA/stroke patients with preexisting NVAF remains suboptimal. In this study, only 53% of patients with NVAF and a CHADS≥2 were treated with anticoagulants. This study emphasizes the need for increased efforts to encourage prescribing of oral anticoagulants in high-risk individuals.

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