January 1, 2020Yonsei Medical JournalOpen Access

Current Anticoagulant Usage Patterns and Determinants in Korean Patients with Nonvalvular Atrial Fibrillation

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Why the study?

Stroke prevention in patients with AF is influenced by many factors, prompting an evaluation of variables associated with the use of warfarin versus direct oral anticoagulants in contemporary practice.

What are the clinical determinants of anticoagulant usage patterns (DOAC vs warfarin vs no OAC) in Korean patients with nonvalvular atrial fibrillation?

Structured PICO

What are the clinical determinants of anticoagulant usage patterns (DOAC vs warfarin vs no OAC) in Korean patients with nonvalvular atrial fibrillation?

Population

10,529 Korean adults (>18 years) with nonvalvular atrial fibrillation, mean age 66.9, 64.9% male. Excluded patients with moderate to severe mitral stenosis, history of valve surgery, deep vein thrombosis, or pulmonary embolism.

Outcome

Determinants of oral anticoagulant (OAC) use, specifically variables associated with the use of warfarin versus direct oral anticoagulants (DOACs) or non-OAC treatment

While overall adherence to oral anticoagulation guidelines is high in Korean patients with atrial fibrillation, inappropriate combination therapy with antiplatelet agents remains common (73.6% without indication).

Limitations

Transversal observational study unable to ascertain longitudinal adherence
Results from a Korean population may not be extrapolated to other populations
Referral bias as all patients were enrolled from tertiary centers

Implication

ESRD strongly associated with non-OAC use in high-risk Korean AF; leaves open optimal strategies for this subgroup and sex-specific DOAC preferences.

Abstract

PURPOSE: Stroke prevention in patients with atrial fibrillation (AF) is influenced by many factors. Using a contemporary registry, we evaluated variables associated with the use of warfarin or direct oral anticoagulants (OACs). MATERIALS AND METHODS: In the prospective multicenter CODE-AF registry, 10529 patients with AF were evaluated. Multivariate analyses were performed to identify variables associated with the use of anticoagulants. RESULTS: The mean age of the patients was 66.9±14.4 years, and 64.9% were men. The mean CHA₂DS₂-VASc and HAS-BLED scores were 2.6±1.7 and 1.8±1.1, respectively. In patients with high stroke risk (CHA₂DS₂-VASc ≥2), OACs were used in 83.2%, including direct OAC in 68.8%. The most important factors for non-OAC treatment were end-stage renal disease [odds ratio (OR) 0.27; 95% confidence interval (CI): 0.19-0.40], myocardial infarct (OR 0.53; 95% CI: 0.40-0.72), and major bleeding (OR 0.57; 95% CI: 0.39-0.84). Female sex (OR 1.40; 95% CI: 1.21-1.61), cancer (OR 1.78; 95% CI: 1.38-2.29), and smoking (OR 1.60; 95% CI: 1.15-2.24) were factors favoring direct OAC use over warfarin. Among patients receiving OACs, the rate of combined antiplatelet agents was 7.8%. However, 73.6% of patients did not have any indication for a combination of antiplatelet agents. CONCLUSION: Renal disease and history of valvular heart disease were associated with warfarin use, while cancer and smoking status were associated with direct OAC use in high stroke risk patients. The combination of antiplatelet agents with OAC was prescribed in 73.6% of patients without definite indications recommended by guidelines.