Key result
Among AF patients initially treated with warfarin, 16.3% switched to DOACs, with switching less likely with higher stroke risk (OR 0.92) and more likely with higher bleeding risk (OR 1.12).
Why the study?
Prior DOAC studies focused on treatment-naive patients, leaving the prevalence, patterns, and factors associated with switching from chronic warfarin to DOACs in AF largely unknown.
What are the patterns and predictors of switching from warfarin to DOACs in patients with atrial fibrillation?
Cohort (n=383,008)
Yes
What are the patterns and predictors of switching from warfarin to DOACs in patients with atrial fibrillation?
Absolute Event Rate: 16.3% vs 68.8%
One in six AF patients on chronic warfarin switched to DOACs, with switching more common in those with higher bleeding risk but lower stroke risk, highlighting substantial practice-level variation.
Switching from warfarin to DOACs in AF tracks bleeding over stroke risk; leaves open optimal real-world thresholds pending prospective data.
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.
No takes yet. Share an insight, caveat, or question.
Sciria et al. (2020) conducted a cohort in Atrial fibrillation (n=383,008). Switching to DOACs vs. Continued warfarin was evaluated on Switching from chronic warfarin therapy to a DOAC. Among AF patients initially treated with warfarin, 16.3% switched to DOACs, with switching less likely with higher stroke risk (OR 0.92) and more likely with higher bleeding risk (OR 1.12).
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: