Key result
The 2019 ACC/AHA/HRS guidelines did not significantly change overall oral anticoagulation use (75.6% vs 75.7%, p=0.79), but DOAC use increased from 36.2% to 38.7% (p<0.001).
Why the study?
The 2019 ACC/AHA/HRS guidelines established DOACs as first-line therapy over warfarin for non-valvular AF, prompting evaluation of OAC use in a rural setting.
Did the 2019 ACC/AHA/HRS guidelines increase the use of DOACs in high-risk non-valvular atrial fibrillation patients in a rural setting?
Observational (n=8,032)
Did the 2019 ACC/AHA/HRS guidelines increase the use of DOACs in high-risk non-valvular atrial fibrillation patients in a rural setting?
Absolute Event Rate: 75.7% vs 75.6%
p-value: p=0.79
Despite updated guidelines recommending DOACs as first-line therapy, overall oral anticoagulation rates remained unchanged in rural AF patients, with a marginal shift from warfarin to DOACs hindered by cost and bleeding risk concerns.
Guidelines had limited impact on overall OAC rates in rural AF; leaves open whether addressing cost and bleeding barriers can improve DOAC uptake.
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 CHA2DS2-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%, p = 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%, p < 0.001 for both). At 1-year, age, male gender, CHA2DS2-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 (p < 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.
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Brod et al. (2022) conducted an observational in Non-valvular atrial fibrillation (n=8,032). 2019 ACC/AHA/HRS guidelines publication vs. Before guideline publication was evaluated on Overall oral anticoagulation use (p=0.79). The 2019 ACC/AHA/HRS guidelines did not significantly change overall oral anticoagulation use (75.6% vs 75.7%, p=0.79), but DOAC use increased from 36.2% to 38.7% (p<0.001).
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