Michela Orlandi1, Douglas C Dover2, Roopinder K Sandhu3, Nathaniel M Hawkins4, Padma Kaul5, Finlay A McAlister6. 1. San Carlo Emergency Department, ASST Santi Paolo e Carlo, Milan, Italy. 2. Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada. 3. Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA. 4. Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada. 5. Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. 6. Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. Electronic address: Finlay.McAlister@ualberta.ca.
Abstract
BACKGROUND: The extent to which the introduction of direct oral anticoagulants (DOACs) influenced treatment patterns in frail and nonfrail patients with nonvalvular atrial fibrillation (NVAF) is unclear. METHODS: This was a retrospective cohort study of all Albertans 20 years or older who were discharged from an emergency department or hospital with a new diagnosis of NVAF between April 1, 2009, and March 31, 2019. The Hospital Frailty Risk Score was used to define frailty and the CHA2DS2-VASc and CHADS-65 scores were used to identify if anticoagulation was indicated. RESULTS: Among 75,796 patients (median age, 75 years; 45% female) with a new diagnosis of NVAF, 17,143 (22.6%) were frail. Although guideline criteria for anticoagulation were more commonly met by frail patients than nonfrail patients (92.1% vs 74.2%, for CHA2DS2-VASc, and 96.8% vs 85.8% for CHADS-65; both P < 0.0001), frail patients were less likely to receive any anticoagulant, even after those with contraindications to anticoagulation were excluded (adjusted odds ratio, 0.61; 95% confidence interval, 0.58-0.64). After DOACs became available, anticoagulant prescribing for patients with guideline indications increased more in nonfrail patients (from 42.4% to 68.2%) than in frail patients (from 29.0% to 52.2%) and frail patients were less likely to receive a DOAC than warfarin (adjusted odds ratio, 0.66; 95% confidence interval, 0.54-0.81). CONCLUSIONS: Although they stand to potentially derive greater benefits from anticoagulation, frail patients were less likely to receive an anticoagulant and, if anticoagulated, they were more likely to receive warfarin than a DOAC. The introduction of DOACs has increased anticoagulation rates but not resolved treatment gaps for frail patients with NVAF.
BACKGROUND: The extent to which the introduction of direct oral anticoagulants (DOACs) influenced treatment patterns in frail and nonfrail patients with nonvalvular atrial fibrillation (NVAF) is unclear. METHODS: This was a retrospective cohort study of all Albertans 20 years or older who were discharged from an emergency department or hospital with a new diagnosis of NVAF between April 1, 2009, and March 31, 2019. The Hospital Frailty Risk Score was used to define frailty and the CHA2DS2-VASc and CHADS-65 scores were used to identify if anticoagulation was indicated. RESULTS: Among 75,796 patients (median age, 75 years; 45% female) with a new diagnosis of NVAF, 17,143 (22.6%) were frail. Although guideline criteria for anticoagulation were more commonly met by frail patients than nonfrail patients (92.1% vs 74.2%, for CHA2DS2-VASc, and 96.8% vs 85.8% for CHADS-65; both P < 0.0001), frail patients were less likely to receive any anticoagulant, even after those with contraindications to anticoagulation were excluded (adjusted odds ratio, 0.61; 95% confidence interval, 0.58-0.64). After DOACs became available, anticoagulant prescribing for patients with guideline indications increased more in nonfrail patients (from 42.4% to 68.2%) than in frail patients (from 29.0% to 52.2%) and frail patients were less likely to receive a DOAC than warfarin (adjusted odds ratio, 0.66; 95% confidence interval, 0.54-0.81). CONCLUSIONS: Although they stand to potentially derive greater benefits from anticoagulation, frail patients were less likely to receive an anticoagulant and, if anticoagulated, they were more likely to receive warfarin than a DOAC. The introduction of DOACs has increased anticoagulation rates but not resolved treatment gaps for frail patients with NVAF.