Overall results showed large geographic variation in the use of oral anticoagulation in stroke prevention, with patients in the Midwest (0.54) and Northeast (0.54) having the greatest likelihood of any OAC initiated; the lowest likelihood was in the South (0.47). The mean adjusted probability of initiating OAC was 0.51, ranging from 0.32 to 0.72. Researchers noted that “anticoagulation use was lowest in Texas, Oklahoma, Missouri, Arkansas, Mississippi, and North Carolina, all of which are well known for having unusually high rates of stroke.”

Patients on OACs were less likely to be prescribed NOACs in regions with higher anticoagulation use than in regions with less anticoagulant use (correlation coefficient, −0.16; p = 0.006). Specifically, the mean adjusted probability of a NOAC being prescribed among those on oral anticoagulation was 0.42 and was highest in the South (0.50) and lowest in the Midwest (0.36) and Northeast (0.39).

“Because oral anticoagulation use was lowest in regions with the highest stroke incidence rates, the implementation of interventions targeted at increasing the use of oral anticoagulation in AFib could have high potential to decrease the incidence of stroke in these areas,” researchers said. “In future studies, it will be important to analyze whether the unusually high rates of stroke in the stroke belt are partially attributed to the underuse of oral anticoagulation in this region.”

Hernandez I, Saba S, Zhang Y. Stroke 2017; June 27:[Epub ahead of print].

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Researchers divided 133 “previously statin-naïve” FH homozygotes from South Africa and the UK into quartiles based on their on-treatment levels of serum cholesterol. The occurrence of any death, cardiovascular death and major adverse cardiovascular events (MACE) was compared between quartiles during 25 years of follow-up.

For an on-treatment serum cholesterol >583 mg/dl, the hazard ratio was 11.5 for any death compared with a level <313 mg/dl. A level of on-treatment cholesterol between 313-583 mg/dl had a hazard ratio of 3.6 compared with >583 mg/dl. These differences were statistically significant and remained so after adjustments for confounding factors. Significant difference were observed between quartiles for cardiovascular death and MACE.

Thompson GR, Blom DJ, Marais AD, et al. Eur Heart J 2017;July 1:[Epub ahead of print].

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Results showed only one in five AFib patients received rhythm control, while only one in 50 received catheter ablation, the most recent innovation in AFib treatment. The study assessed patient (age, gender, race, insurance type and more) and practice (number of providers, area type and practice region) factors associated with rhythm control treatment.

Patients who received rhythm control were more likely to be younger (69 years), white (76 percent) and privately insured (56 percent) than those who were not treated with rhythm control therapy (72 years old, 58 percent white and 51 percent privately insured).

Additionally, there was significant variation in the proportion of patients who received rhythm control based on practice factors (median 22.8 percent). The proportion of AFib patients who received catheter ablation also varied (median 0.3 percent ). Nearly half (46.1 percent) of practices using rhythm control did not treat patients with catheter ablation.

“Our finding that race, insurance and whether a patient was seen by an EP [electrophysiologist] physician are significant patient and practice factors associated with rhythm control further suggests that differential access, potentially by socioeconomic status, may be a driver of differential treatments,” write the study authors.

They conclude that “although current guidelines suggest that patient factors […] should guide treatment decisions, there is evidence of large unexplained practice variation and unnecessary patient factor variation in rhythm control and catheter ablation decisions. By identifying the factors that lead to differences in treatment strategies, we can determine their appropriateness and better align rhythm control use to optimize patient outcomes in AF[ib].”

Gehi AK, Doros G, Glorioso TJ, et al. Am Heart J 2017;187:88-97.

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