Brod Camille, Groth Nicole, Rudeck Macaela, Artang Ramin, Rioux Matthew, Benziger Catherine
University of Minnesota Medical School - Duluth Campus, Duluth, MN, United States.
Essentia Institute of Rural Health, Duluth, MN, United States.
Am J Med Open. 2022 Oct 13;9:100026. doi: 10.1016/j.ajmo.2022.100026. eCollection 2023 Jun.
The 2019 ACC/AHA/HRS guidelines established direct oral anticoagulants (DOACs) as first line therapy over warfarin for non-valvular atrial fibrillation (AF).
Ambulatory clinic patients with non-valvular AF or atrial flutter seen between 10/1/2019-7/12/2020 included. High-risk AF defined as males CHADS-VASc score ≥2 and females ≥3. Patients were separated into: warfarin, DOAC, or no oral anticoagulation (OAC). ATRIA bleed score calculated. A provider survey assessing knowledge and barriers to anticoagulation completed via REDCap between 3/5-4/16/2020.
Of 12,014 subjects with AF, 8,032 were high risk (mean age 75.9 ± 9.8 years; 57.5% male). There were 4,619 (57.1%) ≥ 75 years and 63.4% were rural dwelling. There was no significant difference between the number of subjects on anticoagulation before and after the guideline publication (75.6% vs. 75.7%, = 0.79). Warfarin use decreased 2.3% over 1 year (39.3% to 37.0%), while DOACs increased 2.4% (36.2% to 38.7%, < 0.001 for both). At 1-year, age, male gender, CHADS-VASc score 4-6, hypertension, stroke and cardiology consult increased prescription of OAC (p<0.05). Vascular disease, high risk ATRIA bleed, renal disease, prior hemorrhage, and left atrial appendage occlusion were associated with decreased OAC use ( < 0.05). Left atrial appendage occlusion device use was low (<1%). In a survey, majority of providers noted bleeding risk (35.1%) and cost (25.0%) to be the biggest barriers to DOAC use.
The new guidelines caused a slight increase in DOACs over time. Significant barriers to DOAC use exist in rural areas; one in four high risk AF patient remains without OAC therapy.
2019年美国心脏病学会（ACC）/美国心脏协会（AHA）/美国心律学会（HRS）指南将直接口服抗凝剂（DOACs）确立为非瓣膜性心房颤动（AF）优于华法林的一线治疗药物。
纳入2019年10月1日至2020年7月12日期间门诊就诊的非瓣膜性AF或心房扑动患者。高危AF定义为男性CHADS-VASc评分≥2分且女性≥3分。患者被分为：华法林组、DOAC组或无口服抗凝治疗（OAC）组。计算ATRIA出血评分。通过REDCap在2020年3月5日至4月16日期间完成一项评估抗凝知识和障碍的医疗服务提供者调查。
在12014例AF患者中，8032例为高危患者（平均年龄75.9±9.8岁；男性占57.5%）。年龄≥75岁的患者有4619例（57.1%），63.4%居住在农村。指南发布前后接受抗凝治疗的患者数量无显著差异（75.6%对75.7%，P=0.79）。华法林的使用在1年内下降了2.3%（从39.3%降至37.0%），而DOACs的使用增加了2.4%（从36.2%增至38.7%，两者P均<0.001）。在1年时，年龄、男性、CHADS-VASc评分4 - 6分、高血压、中风和心脏病会诊增加了OAC的处方率（P<0.05）。血管疾病、高危ATRIA出血、肾脏疾病、既往出血和左心耳封堵与OAC使用减少相关（P<0.05）。左心耳封堵装置的使用率较低（<1%）。在一项调查中，大多数医疗服务提供者指出出血风险（35.1%）和成本（25.0%）是DOAC使用的最大障碍。
随着时间的推移，新指南使DOACs的使用略有增加。农村地区DOAC使用存在重大障碍；四分之一的高危AF患者仍未接受OAC治疗。
