Mark H Eckman1, Alexandru Costea2, Mehran Attari2, Jitender Munjal2, Ruth E Wise3, Carol Knochelmann2, Matthew L Flaherty4, Pete Baker5, Robert Ireton5, Brett M Harnett5, Anthony C Leonard6, Dylan Steen2, Adam Rose3, John Kues6. 1. Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH; Center for Health Informatics, University of Cincinnati, Cincinnati, OH. Electronic address: mark.eckman@uc.edu. 2. Division of Cardiology, University of Cincinnati, Cincinnati, OH. 3. Division of General Internal Medicine and Center for Clinical Effectiveness, University of Cincinnati, Cincinnati, OH. 4. Department of Neurology, University of Cincinnati, Cincinnati, OH. 5. Center for Health Informatics, University of Cincinnati, Cincinnati, OH. 6. Department of Family and Community Medicine, University of Cincinnati, Cincinnati, OH.
Abstract
BACKGROUND: Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. The recent availability of direct oral anticoagulants (DOACs) with comparable efficacy and improved safety compared with warfarin alters the balance between risk factors for stroke and benefit of anticoagulation. Our objective was to examine the impact of DOACs as an alternative to warfarin on the net benefit of oral anticoagulant therapy (OAT) in a real-world population of AF patients. METHODS: This is a retrospective cohort study of patients with paroxysmal or persistent nonvalvular AF. We updated an Atrial Fibrillation Decision Support Tool (AFDST) to include DOACs as treatment options. The tool generates patient-specific recommendations based upon individual patient risk factor profiles for stroke and major bleeding using quality-adjusted life-years (QALYs) calculated for each treatment strategy by a decision analytic model. The setting included inpatient and ambulatory sites in an academic health center in the midwestern United States. The study involved 5,121 adults with nonvalvular AF seen for any ambulatory visit or inpatient hospitalization over the 1-year period (January through December 2016). Outcome measure was net clinical benefit in QALYs. RESULTS: When DOACs are a therapeutic option, the AFDST recommends OAT for 4,134 (81%) patients and no antithrombotic therapy or aspirin for 489 (9%). A strong recommendation for OAT could not be made in 498 (10%) patients. When warfarin is the only option, OAT is recommended for 3,228 (63%) patients and no antithrombotic therapy or aspirin for 973 (19%). A strong recommendation for OAT could not be made in 920 (18%) patients. In total, 1,508 QALYs could be gained if treatment were changed to that recommended by the AFDST. CONCLUSIONS: Availability of DOACs increases the proportion of patients for whom oral anticoagulation therapy is recommended in a real-world cohort of AF patients and increased projected QALYs by more than 1,500 when all patients are receiving thromboprophylaxis as recommended by the AFDST compared with current treatment.
BACKGROUND: Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. The recent availability of direct oral anticoagulants (DOACs) with comparable efficacy and improved safety compared with warfarin alters the balance between risk factors for stroke and benefit of anticoagulation. Our objective was to examine the impact of DOACs as an alternative to warfarin on the net benefit of oral anticoagulant therapy (OAT) in a real-world population of AFpatients. METHODS: This is a retrospective cohort study of patients with paroxysmal or persistent nonvalvular AF. We updated an Atrial Fibrillation Decision Support Tool (AFDST) to include DOACs as treatment options. The tool generates patient-specific recommendations based upon individual patient risk factor profiles for stroke and major bleeding using quality-adjusted life-years (QALYs) calculated for each treatment strategy by a decision analytic model. The setting included inpatient and ambulatory sites in an academic health center in the midwestern United States. The study involved 5,121 adults with nonvalvular AF seen for any ambulatory visit or inpatient hospitalization over the 1-year period (January through December 2016). Outcome measure was net clinical benefit in QALYs. RESULTS: When DOACs are a therapeutic option, the AFDST recommends OAT for 4,134 (81%) patients and no antithrombotic therapy or aspirin for 489 (9%). A strong recommendation for OAT could not be made in 498 (10%) patients. When warfarin is the only option, OAT is recommended for 3,228 (63%) patients and no antithrombotic therapy or aspirin for 973 (19%). A strong recommendation for OAT could not be made in 920 (18%) patients. In total, 1,508 QALYs could be gained if treatment were changed to that recommended by the AFDST. CONCLUSIONS: Availability of DOACs increases the proportion of patients for whom oral anticoagulation therapy is recommended in a real-world cohort of AFpatients and increased projected QALYs by more than 1,500 when all patients are receiving thromboprophylaxis as recommended by the AFDST compared with current treatment.
Authors: Craig T January; L Samuel Wann; Joseph S Alpert; Hugh Calkins; Joaquin E Cigarroa; Joseph C Cleveland; Jamie B Conti; Patrick T Ellinor; Michael D Ezekowitz; Michael E Field; Katherine T Murray; Ralph L Sacco; William G Stevenson; Patrick J Tchou; Cynthia M Tracy; Clyde W Yancy Journal: J Am Coll Cardiol Date: 2014-03-28 Impact factor: 24.094
Authors: Benjamin A Steinberg; Peter Shrader; Laine Thomas; Jack Ansell; Gregg C Fonarow; Bernard J Gersh; Peter R Kowey; Kenneth W Mahaffey; Gerald Naccarelli; James Reiffel; Daniel E Singer; Eric D Peterson; Jonathan P Piccini Journal: J Am Coll Cardiol Date: 2016-12-20 Impact factor: 24.094
Authors: Carl van Walraven; Robert G Hart; Daniel E Singer; Andreas Laupacis; Stuart Connolly; Palle Petersen; Peter J Koudstaal; Yuchiao Chang; Beppie Hellemons Journal: JAMA Date: 2002-11-20 Impact factor: 56.272
Authors: Mark H Eckman; Gregory Y H Lip; Ruth E Wise; Barbara Speer; Megan Sullivan; Nita Walker; Brett Kissela; Matthew L Flaherty; Dawn Kleindorfer; Peter Baker; Robert Ireton; Dave Hoskins; Brett M Harnett; Carlos Aguilar; Anthony Leonard; Lora Arduser; Dylan Steen; Alexandru Costea; John Kues Journal: J Am Geriatr Soc Date: 2016-05 Impact factor: 5.562
Authors: Sachin J Shah; Daniel E Singer; Margaret C Fang; Kristi Reynolds; Alan S Go; Mark H Eckman Journal: Circ Cardiovasc Qual Outcomes Date: 2019-11-11
Authors: Robert J Stanton; Mark H Eckman; Daniel Woo; Charles J Moomaw; Mary Haverbusch; Matthew L Flaherty; Dawn O Kleindorfer Journal: Stroke Date: 2020-01-31 Impact factor: 7.914
Authors: Felix M Bläsius; Markus Laubach; Hagen Andruszkow; Cavan Lübke; Philipp Lichte; Rolf Lefering; Frank Hildebrand; Klemens Horst Journal: Sci Rep Date: 2021-07-26 Impact factor: 4.379