Oral Anticoagulant Use Among Residents in VA Long-Term Care With Atrial Fibrillation After the 2014 ACC/AHA Guideline

OBJECTIVES In 2014, the American College of Cardiology/American Heart Association moved away from recommending aspirin in atrial fibrillation (AF) and recommended that patients be treated with oral anticoagulants (OACs) to mitigate the risk of stroke. We aimed to evaluate the prevalence and predictors of OACs and/or aspirin use among veterans with AF in Veterans Affairs nursing homes in the era after the guideline publication. DESIGN Observational study of veterans admitted from October 1, 2014 to September 30, 2019. SETTING AND PARTICIPANTS Four thousand nine hundred ninety-four nursing home residents with AF and a CHA2DS2-VASc score of ≥2. METHODS Multinomial logistic regression was used to compare demographics, comorbidities, functional status, and concurrent antiplatelet medication use in residents who received OAC ± aspirin and aspirin alone, compared with neither. RESULTS In the era after the 2014 American College of Cardiology/American Heart Association guideline was released, age-standardized prevalence rates for any OAC (warfarin and direct oral anticoagulant) increased from 31.2% in fiscal year (FY) 2013 to 2014 to 46.6% in FY 2019. In addition, there was a decrease in patients receiving no OAC (21.1%-16.2%) and aspirin (47.7%-39.3%). However, some eligible residents remained untreated. Averaged over FY 2015 to 2019, each decade of ascending age was associated with a lower likelihood of receiving OAC [relative risk ratio (RRR), 0.79; 95% CI, 0.71-0.87], relative to neither anticoagulant nor aspirin use. Black veterans were less likely to receive OAC (RRR, 0.73; 95% CI, 0.58-0.91); Hispanic veterans were less likely to receive OAC (RRR, 0.63; 95% CI, 0.44-0.91) and aspirin (RRR, 0.47; 95% CI, 0.31-0.72). Mild to moderate cognitive impairment, greater disability, and other antiplatelet use were also associated with less OAC use. CONCLUSIONS AND IMPLICATIONS Fewer Veterans Affairs nursing home residents received OACs than recommended by guidelines, with significant differences by age and race/ethnicity. Future research efforts should aim to understand the reasons for low OAC use and to augment the evidence base for anticoagulant use to include frail older adults.