What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Nonvalvular atrial fibrillation (n=11056). Intervention: Aspirin use vs. No aspirin use. Primary outcome: Oral anticoagulant utilization (OR 0.097, 95% CI 0.085-0.110, p=<0.001).

January 1, 2022Open Access

Underutilization of anticoagulants in patients with nonvalvular atrial fibrillation in the era of non-vitamin K antagonist oral anticoagulants

Q: What are the key findings of this study?

Aspirin use was strongly associated with decreased oral anticoagulant utilization (OR 0.097) in elderly patients with nonvalvular atrial fibrillation, highlighting its inappropriate use as an alternative.

SPSusin ParkKyungsung University NJNam Kyung JePusan National University

Key Result

Aspirin use was strongly associated with decreased oral anticoagulant utilization (OR 0.097) in elderly patients with nonvalvular atrial fibrillation, highlighting its inappropriate use as an alternative.

Study Design

Type

Cross-Sectional (n=11,056)

Structured PICO

What is the current status and what are the risk factors for oral anticoagulant underutilization in elderly patients with nonvalvular atrial fibrillation in the NOAC era?

Population

11,056 elderly adults (aged ≥65 years) in South Korea with nonvalvular atrial fibrillation and a CHA2DS2-VASc score ≥2, evaluated cross-sectionally for oral anticoagulant utilization.

Exposure

Oral anticoagulants (OACs), including non-vitamin K antagonist oral anticoagulants (NOACs: dabigatran, rivaroxaban, apixaban, edoxaban) and warfarin

Outcome

Status of oral anticoagulant utilization on the index date (July 1, 2018) and factors influencing the use of anticoagulants

Despite the availability of NOACs, approximately one-third of elderly patients with NVAF at high risk for stroke remain undertreated with oral anticoagulants, often inappropriately receiving aspirin instead.

Main Result

Odds Ratio: 0.097 (95% CI 0.085–0.11)

Absolute Event Rate: 21.9% vs 73.6%

p-value: p=<0.001

Limitations

Claims data may be susceptible to upcoding by providers seeking higher reimbursement rates
Data did not include uninsured events, such as over-the-counter aspirin use
Lacked clinical data such as laboratory test results, disease severity, or patient-reported outcomes
Socioeconomic factors such as income, education, and health behaviors were not reflected
Atrial fibrillation types are difficult to distinguish clearly in claims data

Abstract

Non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over vitamin K antagonists (VKAs) as oral anticoagulant (OAC) therapy in patients with nonvalvular atrial fibrillation (NVAF). This study aimed to estimate the current status and risk factors of OAC underutilization in the NOAC era. A cross-sectional study using nationwide claims data was conducted. Elderly patients with NVAF at an increased risk of stroke were selected as candidates for OAC therapy before the index date (July 1, 2018). The status of anticoagulant utilization on the index date and factors influencing the use of anticoagulants was investigated in these patients. Of the 11,056 patients with NVAF who were eligible for OAC therapy, 7238 (65.5%) were receiving OAC on the index date, and 6302 (87.1%) were receiving NOACs. Patients aged ≥ 75 years had higher anticoagulant utilization than those aged 65–69 years. Among comorbid diseases, while hypertension was the most influential positive factor (odds ratio OR = 1.644; confidence interval CI = 1.445–1.869) in OAC utilization, severe renal disease was the most influential negative factor (OR = 0.289; CI = 0.200–0.416). Aspirin use had a significantly low OR (OR = 0.097; CI = 0.085–0.110) of anticoagulant use. OAC use was approximately 1.5 times higher in patients with persistent or permanent AF than in those with paroxysmal AF. Approximately one-third of patients who are recommended anticoagulation therapy do not take OACs, even though the use of NOACs has become more common. It should be widely recognized that aspirin cannot be an alternative to OACs, and anticoagulant therapy should be actively implemented.

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