Sussman Matthew, Barnes Geoffrey D, Guo Jennifer D, Tao Charles Y, Gillespie John A, Ferri Mauricio, Adair Nicholas, Cato Matthew S, Shirkhorshidian Ilnaz, Di Fusco Manuela
Modeling and Strategy Services, Panalgo LLC, Boston, MA, USA.
School of Medicine, University of Michigan, Ann Arbor, MI, USA.
Curr Med Res Opin. 2022 Jan;38(1):7-18. doi: 10.1080/03007995.2021.1982684. Epub 2021 Oct 9.
Global treatment guidelines recommend treatment with oral anticoagulants (OACs) for patients with non-valvular atrial fibrillation (NVAF) and an elevated stroke risk. However, not all patients with NVAF and an elevated stroke risk receive guideline-recommended therapy. A literature review and synthesis of observational studies were undertaken to identify the body of evidence on untreated and undertreated NVAF and the association with clinical and economic outcomes.
An extensive search (1/2010-4/2020) of MEDLINE, the Cochrane Library, conference proceedings, and health technology assessments (HTAs) was conducted. Studies must have evaluated rates of nontreatment or undertreatment in NVAF. Nontreatment was defined as absence of OACs (but with possible antiplatelet treatment), while undertreatment was defined as treatment with only antiplatelet agents.
Sixteen studies met our inclusion criteria. Rates of nontreatment for patients with elevated stroke risk ranged from 2.0-51.1%, while rates of undertreatment ranged from 10.0-45.1%. The clinical benefits of anticoagulation were reported in the evaluated studies with reductions in stroke and mortality outcomes observed among patients treated with anticoagulants compared to untreated or undertreated patients. Adverse events associated with all bleeding types (i.e. hemorrhagic stroke, major bleeding or gastrointestinal hemorrhaging) were found to be higher for warfarin patients compared to untreated patients in real-world practice. Healthcare resource utilization was found to be lower among patients highly-adherent to warfarin compared to untreated patients.
Rates of nontreatment and undertreatment among NVAF patients remain high and are associated with preventable cardiovascular events and death. Strategies to increase rates of treatment may improve clinical outcomes.
全球治疗指南推荐对非瓣膜性心房颤动（NVAF）且卒中风险升高的患者使用口服抗凝剂（OAC）进行治疗。然而，并非所有NVAF且卒中风险升高的患者都接受指南推荐的治疗。进行了一项文献综述和观察性研究的综合分析，以确定关于未治疗和治疗不足的NVAF以及与临床和经济结局之间关联的证据。
对MEDLINE、Cochrane图书馆、会议论文集和卫生技术评估（HTA）进行了广泛检索（2010年1月 - 2020年4月）。研究必须评估NVAF的未治疗或治疗不足率。未治疗定义为未使用OAC（但可能使用抗血小板治疗），而治疗不足定义为仅使用抗血小板药物治疗。
16项研究符合我们的纳入标准。卒中风险升高患者的未治疗率在2.0 - 51.1%之间，而治疗不足率在10.0 - 45.1%之间。在评估的研究中报告了抗凝的临床益处，与未治疗或治疗不足的患者相比，接受抗凝治疗的患者卒中及死亡率降低。在实际临床中，与所有出血类型（即出血性卒中、大出血或胃肠道出血）相关的不良事件在华法林治疗患者中高于未治疗患者。与未治疗患者相比，华法林高依从性患者的医疗资源利用率较低。
NVAF患者的未治疗和治疗不足率仍然很高，并且与可预防的心血管事件和死亡相关。提高治疗率的策略可能会改善临床结局。
