Novel Oral Anticoagulants in Hospitalized AF and Stroke Patients | Journal Scan

Study Questions:

How often are novel oral anticoagulants (NOACs) used in patients hospitalized with atrial fibrillation (AF) and an ischemic stroke or transient ischemic attack (TIA)?

Methods:

Using the Get With The Guidelines-Stroke database, 61,655 patients with AF were hospitalized for an ischemic stroke or TIA between 2010 and 2012, and discharged on warfarin or a NOAC (dabigatran or rivaroxaban). Factors associated with NOAC versus warfarin use were explored using multivariable logistic regression.

Results:

In this study population, warfarin was used in 88.9% of patients, whereas dabigatran was used in 9.6% and rivaroxaban in 1.5%. During the study period, use of NOACs increased from 0.04% to 16-17% with a plateau period. There was no significant change in total proportion of patients receiving any anticoagulant during the study period (93.7% vs. 94.1%). Predictors of NOAC use included multiple factors such as younger age (odds ratio [OR], 0.94 per decade; 95% confidence interval [CI], 0.91-0.97), prior anticoagulant use (OR, 0.52; 95% CI, 0.48-0.56), and inability to ambulate (OR, 0.58; 95% CI, 0.51-0.67). Bleeding risk factors and CHA2DS2-VASc score were lower among patients discharged on NOACs as compared to warfarin.

Conclusions:

The authors concluded that the NOACs have had modest, but growing uptake among AF patients admitted with an ischemic stroke or TIA. They also concluded that NOACs were being prescribed to patients with lower stroke risk as compared to warfarin.

Perspective:

This study from the Get With The Guidelines-Stroke database highlights a few interesting findings. First, use of anticoagulants among AF patients admitted with an ischemic stroke or TIA is significantly higher than among the general AF population (~94% vs. ~50%). Second, use of NOACs (also known as direct oral anticoagulants) is more prevalent among lower-risk AF patients. However, the study date (2010-2012) may reflect hesitance during early adoption of these agents as more recent cohorts have not been reflected. NOAC use was significantly less likely among patients on prior warfarin or who are unable to ambulate. It remains to be seen if these trends persist as providers gain more familiarity with the NOACs and as reversal agents become available.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Novel Agents

Keywords: Arrhythmias, Cardiac, Anticoagulants, Atrial Fibrillation, Benzimidazoles, Hospitalization, Ischemic Attack, Transient, Logistic Models, Morpholines, Primary Prevention, Risk Factors, Stroke, Thiophenes, Warfarin, beta-Alanine, Vascular Diseases


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