Author + information
- Received December 15, 2016
- Revision received March 3, 2017
- Accepted March 10, 2017
- Published online May 15, 2017.
- Lucas N. Marzec, MDa,b,∗ (, )
- Jingyan Wang, MSc,
- Nilay D. Shah, PhDd,
- Paul S. Chan, MD, MScc,
- Henry H. Ting, MDe,
- Kensey L. Gosch, MSc,
- Jonathan C. Hsu, MD, MASf and
- Thomas M. Maddox, MD, MScb
- aUniversity of Colorado School of Medicine, Aurora, Colorado
- bVeterans Affairs Eastern Colorado Health Care System, Denver, Colorado
- cMid America Heart Institute, Kansas City, Missouri
- dMayo Clinic, Rochester, Minnesota
- eNew York Presbyterian Hospital, The University Hospital of Columbia and Cornell University, New York, New York
- fUniversity of California, San Diego, La Jolla, California
- ↵∗Address for correspondence:
Dr. Lucas N. Marzec, University of Colorado School of Medicine, 12401 East 17th Avenue, Campus Stop B-132, Aurora, Colorado 80045.
Background 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.
Objectives This study assessed the effect of DOAC availability on overall OAC rates for nonvalvular AF.
Methods 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.
Results 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).
Conclusions 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.
This research was supported by the American College of Cardiology’s National Cardiovascular Data Registry (NCDR). The views expressed in this paper represent those of the authors, and do not necessarily represent the official views of the NCDR or its associated professional societies identified at CVQuality.ACC.org/NCDR.
Dr. Chan has received research support from the National Heart, Lung, and Blood Institute. Dr. Hsu has received honoraria from St. Jude Medical, Medtronic, Biotronik, Janssen Pharmaceuticals, and Bristol-Myers Squibb; and has received research grants from Biosense Webster and Biotronik. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 15, 2016.
- Revision received March 3, 2017.
- Accepted March 10, 2017.
- 2017 American College of Cardiology Foundation