Key result
Antiplatelet monotherapy is prescribed to ~21% of new AF patients, linked to CAD and persistent AF.
Why the study?
Current AF guidelines discourage antiplatelet monotherapy as an alternative to anticoagulants, but why antiplatelet monotherapy is still used is largely unknown.
What factors are associated with the prescription of antiplatelet monotherapy compared to anticoagulant monotherapy in patients with newly diagnosed atrial fibrillation?
Cohort (n=51,270)
Yes
What factors are associated with the prescription of antiplatelet monotherapy compared to anticoagulant monotherapy in patients with newly diagnosed atrial fibrillation?
Absolute Event Rate: 20.7% vs 52.1%
Despite guideline recommendations against it, a substantial proportion of patients with newly diagnosed atrial fibrillation still receive antiplatelet monotherapy without a clear indication, although this practice is declining.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“This evolution in treatment patterns is consistent with the adoption of innovative therapies for stroke prevention. The remaining challenge, however, is to ensure that the correct patient receives the appropriate therapy.”
“These 1-year data from GARFIELD illustrate that evidence-based stroke prevention guidelines are not always followed in everyday clinical practice. Taken together, these new findings re-emphasize what has been observed in clinical trials regarding stroke risk in AF patients. The research suggests there are opportunities to improve patient outcomes through more consistent application of best practice and adoption of the many innovative therapies to prevent stroke in high-risk AF patients.”
“We know that atrial fibrillation carries a significant stroke risk and anticoagulants can reduce that risk by more that 60 percent; however, GARFIELD data suggest a lower utilization than would be anticipated based on clinical trial evidence and current treatment guidelines. Too many patients remain unprotected, and understanding the reasons for this will help in the appropriate adoption of innovative strategies to prevent stroke and improve clinical outcomes.”
AP monotherapy persists in new AF despite guidelines; leaves open patient- and system-level drivers for targeted interventions.
Aims: Current atrial fibrillation (AF) guidelines discourage antiplatelet (AP) monotherapy as alternative to anticoagulants (ACs). Why AP only is still used is largely unknown. Methods and results: Factors associated with AP monotherapy prescription were analysed in GARFIELD-AF, a registry of patients with newly diagnosed (≤6 weeks) AF and ≥1 investigator-determined stroke risk factor. We analysed 51 270 patients from 35 countries enrolled into five sequential cohorts between 2010 and 2016. Overall, 20.7% of patients received AP monotherapy, 52.1% AC monotherapy, and 14.1% AP + AC. Most AP monotherapy (82.5%) and AC monotherapy (86.8%) patients were CHA2DS2-VASc ≥2. Compared with patients on AC monotherapy, AP monotherapy patients were frequently Chinese (vs. Caucasian, odds ratio 2.73) and more likely to have persistent AF (1.32), history of coronary artery disease (2.41) or other vascular disease (1.67), bleeding (2.11), or dementia (1.81). The odds for AP monotherapy increased with 5 years of age increments for patients ≥75 years (1.24) but decreased with age increments for patients 55-75 years (0.86). Antiplatelet monotherapy patients were less likely to have paroxysmal (0.67) or permanent AF (0.57), history of embolism (0.56), or alcohol use (0.90). With each cohort, AP monotherapy declined (P<0.0001), especially non-indicated use. AP + AC and no antithrombotic therapy were unchanged. However, even in 2015 and 2016, about 50% of AP-treated patients had no indication except AF (71% were CHA2DS2-VASc ≥2). Conclusion: Prescribing AP monotherapy in newly diagnosed AF has declined, but even nowadays a substantial proportion of AP-treated patients with AF have no indication for AP. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362.
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Verheugt et al. (2017) conducted a cohort in Atrial fibrillation (n=51,270). Antiplatelet monotherapy vs. Anticoagulant monotherapy was evaluated on Prescription of antiplatelet monotherapy. Among 51,270 patients with newly diagnosed atrial fibrillation, 20.7% received antiplatelet monotherapy, which was associated with Chinese ethnicity, persistent AF, and coronary artery disease.
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