Abstract
Objective
To assess the influence of guideline-adherent vs nonadherent antithrombotic treatment
(ATT) on stroke and mortality rates in an atrial fibrillation (AF) primary care population.
Patients and Methods
We used the Darlington Registry cohort, which included 105,000 patients from March
31, 2012, through March 31, 2013. Guideline adherence in ATT was assessed against
2014 National Institute for Health and Care Excellence guidelines, which recommend
oral anticoagulation for stroke prevention as a default management unless a truly
low risk of stroke (CHA2DS2-VASc=0 in men and 1 in women) is evident.
Results
Of 2259 patients with AF (2.15%), 36.1% were undertreated, 50.8% were guideline adherent,
and 13.1% were overtreated. Oral anticoagulation was declined by 5.0% and contraindicated
in 8.3%. Of 67 incident strokes (3.0%), 66 (98.5%) occurred in high-risk patients
(CHA2DS2-VASc ≥2). For the high-risk cohort, 1-year stroke rates were 4.5% (95% CI, 3.2%-6.3%)
for undertreatment, 1.9% (95% CI, 1.2%-2.9%) for guideline adherence, and 7.2% (95%
CI, 4.4%-11.6%) for overtreatment; corresponding mortality rates were 16.1% (95% CI,
13.6%-19.0%), 8.0% (95% CI, 6.5%-9.8%), and 8.2% (95% CI, 5.2%-12.7%), respectively.
On multivariable analysis, both undertreatment and overtreatment of high-risk patients
were associated with significant increases in stroke rates (odds ratio [OR]=2.32;
95% CI, 1.30-3.14; P=.005 and OR=2.28; 95% CI, 1.12-4.63; P=.02, respectively). Undertreatment was also associated with a significant increase
in all-cause mortality (OR=1.59; 95% CI, 1.14-2.21; P=.006).
Conclusion
Only half of all eligible patients with AF are prescribed oral anticoagulation in
accordance with guideline recommendations. Guideline-adherent ATT significantly reduces
the risk of stroke and improves survival.
Abbreviations and Acronyms:
AF (atrial fibrillation), ATT (antithrombotic treatment), CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex category), EORP-AF (EURObservational Research Programme–Atrial Fibrillation), GRASP-AF (Guidance on Risk Assessment and Stroke Prevention in Atrial Fibrillation), NICE (National Institute for Health and Care Excellence), NOAC (non–vitamin K antagonist oral anticoagulant), OAC (oral anticoagulation), OR (odds ratio), PE (pulmonary embolism), STE (systemic thromboembolism), TTR (time in therapeutic range)To read this article in full you will need to make a payment
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Article Info
Footnotes
Potential Competing Interests: Dr Lane has received investigator-initiated educational grants from Bayer Healthcare, Bristol-Myers Squibb, and Boehringer Ingelheim; and has been a speaker and consultant for Boehringer Ingelheim, Bayer, and Bristol-Myers Squibb/Pfizer. Dr Wolff has been a clinical advisor to and has received educational grants and investigator payments from Boehringer Ingelheim, Pfizer, Bristol-Myers Squibb, Sanofi Aventis, and Daiichi-Sankyo; and has served as speaker for Boehringer Ingelheim, Sanofi, and Pfizer. Dr Proietti has received consultancy fees from Boehringer Ingelheim. Dr Lip has served as a consultant for Bayer/Janssen, Bristol-Myers Squibb/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Microlife, and Daiichi-Sankyo; and has been a speaker for Bayer, Bristol-Myers Squibb/Pfizer, Medtronic, Boehringer Ingelheim, Microlife, Roche, and Daiichi-Sankyo. Drs Mazurek and Shantsila report no competing interests.
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© 2017 Mayo Foundation for Medical Education and Research
