University of Colorado School of Medicine, Aurora, Colorado; Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.
Mid America Heart Institute, Kansas City, Missouri.
J Am Coll Cardiol. 2017 May 23;69(20):2475-2484. 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 CHADS-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 CHADS-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.
华法林（warfarin）口服抗凝治疗（oral anticoagulation，OAC）在心房颤动（atrial fibrillation，AF）中的应用不足。直接口服抗凝剂（direct oral anticoagulants，DOACs）的应用可能会提高 AF 患者整体 OAC 治疗率，但尚未对此进行大规模评估。
本研究评估 DOAC 应用对非瓣膜性 AF 患者整体 OAC 治疗率的影响。
2008 年 4 月 1 日至 2014 年 9 月 30 日，我们从全国心血管数据登记处 PINNACLE 注册数据库中确定了 65.5 万名 CHADS-VASc 评分＞1 的非瓣膜性 AF 患者。分析整体 OAC 及华法林和 DOAC 单独使用的时间趋势。采用多变量分层逻辑回归确定与 OAC 和 DOAC 使用相关的患者因素。还评估了 OAC 和 DOAC 使用的实践差异。
在符合条件的 AF 患者中，整体 OAC 治疗率从 52.4%增至 60.7%（趋势 p＜0.01）。华法林使用率从 52.4%降至 34.8%（趋势 p＜0.01），而 DOAC 使用率从 0%增至 25.8%（趋势 p＜0.01）。CHADS-VASc 评分升高与 OAC 使用率升高相关（比值比 [odds ratio，OR]：1.06；95%置信区间 [confidence interval，CI]：1.05 至 1.07），但与 DOAC 使用率降低相关（OR：0.97；95%CI：0.96 至 0.98）。OAC 使用率（中位数比值比 [median odds ratio，MOR]：1.52；95%CI：1.45 至 1.57）和 DOAC 使用率（MOR：3.58；95%CI：3.05 至 4.13）存在显著的实践差异。
DOAC 在常规实践中的应用与 AF 患者整体 OAC 治疗率的提高有关，但仍存在显著差距。此外，OAC 和 DOAC 的使用存在显著的实践差异。
