Switching warfarin to direct oral anticoagulants in atrial fibrillation: Insights from the NCDR PINNACLE registry.

Autor: Sciria CT; Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, New York, USA., Maddox TM; Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA., Marzec L; Department of Cardiology, Kaiser Permanente, Lafayette, Colorado, USA., Rodwin B; Division of Cardiology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York, New York, USA.; Department of Medicine, VA Connecticut Healthcare System, West Haven, CT, USA., Virani SS; Michael E. DeBakey Veterans Affairs Medical Center and Section of Cardiovascular Research, Baylor College of Medicine, Houston, Texas, USA., Annapureddy A; Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA., Freeman JV; Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA.; Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA., O'Hare A; Baim Institute for Clinical Research, Boston, Massachusetts, USA., Liu Y; Baim Institute for Clinical Research, Boston, Massachusetts, USA., Song Y; Baim Institute for Clinical Research, Boston, Massachusetts, USA., Doros G; Baim Institute for Clinical Research, Boston, Massachusetts, USA., Zheng Y; Baim Institute for Clinical Research, Boston, Massachusetts, USA., Lee JJ; Baim Institute for Clinical Research, Boston, Massachusetts, USA., Daggubati R; Division of Cardiology, Winthrop University Hospital, Mineola, New York, USA., Vadlamani L; Yale School of Medicine, New Haven, Connecticut, USA., Cannon C; Baim Institute for Clinical Research, Boston, Massachusetts, USA.; Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA., Desai NR; Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA.; Division of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
Jazyk: angličtina
Zdroj: Clinical cardiology [Clin Cardiol] 2020 Jul; Vol. 43 (7), pp. 743-751. Date of Electronic Publication: 2020 May 06.
DOI: 10.1002/clc.23376
Abstrakt: Background: Previous studies examining the use of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) have largely focused on patients newly initiating therapy. Little is known about the prevalence/patterns of switching to DOACs among AF patients initially treated with warfarin.
Hypothesis: To examine patterns of anticoagulation among patients chronically managed with warfarin upon the availability of DOACs and identify patient/practice-level factors associated with switching from chronic warfarin therapy to a DOAC.
Methods: Prospective cohort study of AF patients in the NCDR PINNACLE registry prescribed warfarin between May 1, 2008 and May 1, 2015. Patients were followed at least 1 year (median length of follow-up 375 days, IQR 154-375) through May 1, 2016 and stratified as follows: continued warfarin, switched to DOAC, or discontinued anticoagulation. To identify significant predictors of switching, a three-level multivariable hierarchical regression was developed.
Results: Among 383 008 AF patients initially prescribed warfarin, 16.3% (n = 62 620) switched to DOACs, 68.8% (n = 263 609) continued warfarin, and 14.8% (n = 56 779) discontinued anticoagulation. Among those switched, 37.6% received dabigatran, 37.0% rivaroxaban, 24.4% apixaban, and 1.0% edoxaban. Switched patients were more likely to be younger, women, white, and have private insurance (all P < .001). Switching was less likely with increased stroke risk (OR, 0.92; 95%CI, 0.91-0.93 per 1-point increase CHA 2 DS 2 -VASc), but more likely with increased bleeding risk (OR, 1.12; 95%CI, 1.10-1.13 per 1-point increase HAS-BLED). There was substantial variation at the practice-level (MOR, 2.33; 95%CI, 2.12-2.58) and among providers within the same practice (MOR, 1.46; 95%CI, 1.43-1.49).
Conclusions: Among AF patients treated with warfarin between October 1, 2010 and May 1, 2016, one in six were switched to DOACs, with differences across sociodemographic/clinical characteristics and substantial practice-level variation. In the context of current guidelines which favor DOACs over warfarin, these findings help benchmark performance and identify areas of improvement.
(© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.)
Databáze: MEDLINE
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