Association of Race and Ethnicity With OAC and Outcomes in AF
- Black patients with AF were less likely to receive any oral anticoagulant, including DOAC medications, than White patients upon hospital discharge.
- Black patients with AF were more likely to experience bleeding, stroke, and mortality than White patients following hospital discharge.
- Hispanic patients with AF were more likely to experience stroke than White patients following hospital discharge.
How does oral anticoagulant (OAC) use at hospital discharge and outcomes differ by race and ethnicity for patients in the Get With The Guidelines–Atrial Fibrillation (GWTG-AFIB) registry?
The authors conducted a retrospective cohort analysis using data from the GWTG-AFIB registry, a national quality improvement initiative for hospitalized patients with atrial fibrillation (AF). All patients were hospitalized between 2014 and 2020. The primary outcome was the prescription of a direct OAC (DOAC) or warfarin at hospital discharge. Secondary outcomes included cumulative 1-year incidence of ischemic stroke, major bleeding, and mortality following hospital discharge. All outcomes were adjusted for patient demographic, clinical, and socioeconomic characteristics in addition to hospital factors.
Among 69,553 patients hospitalized with AF at 159 sites, 863 (1.2%) were Asian, 5,062 (7.3%) were Black, 4,058 (5.8%) were Hispanic, and 59,570 (85.6%) were White. The median (interquartile range) CHA2DS2-VASc score was 4 (2-5). At discharge, 56,385 patients (81.1%) were prescribed OAC therapy, including 41,760 (74.1%) who were prescribed a DOAC. OAC prescribing was lowest in Hispanic patients, followed by Black, Asian, and White patients. Black patients were less likely than White patients to be discharged taking any anticoagulant (77.78% vs. 81.8%, adjusted odds ratio [aOR], 0.75; 95% confidence interval [CI], 0.68-0.84) and to be prescribed a DOAC (aOR, 0.73; 95% CI, 0.65-0.82). Among the 16,307 patients with 1-year follow-up, bleeding risk (adjusted hazard ratio [aHR], 2.08; 95% CI, 1.52-2.83), stroke risk (aHR, 2.07; 95% CI, 1.34-3.20), and mortality risk (aHR, 1.22; 95% CI, 1.02-1.47) were all higher among Black as compared to White patients. Hispanic patients also had a higher risk of stroke (aHR, 2.02; 95% CI, 1.38-2.95) as compared to White patients.
The authors concluded that Black patients hospitalized with AF were less likely to be discharged with OAC prescription, less likely to be prescribed a DOAC, and had worse clinical outcomes than White patients.
OAC use is critical for the prevention of stroke and systemic embolism in patients with AF. Over the past decade, DOAC therapy has become first-line given their ease of use and lower rate of severe bleeding (especially intracranial hemorrhage). Within the context of a nationwide quality improvement initiative (GWTG-AFIB), the authors demonstrate that important racial and ethnic disparities exist in three key measures of AF quality. First, the overall use of any OAC was lowest among Black patients as compared to their White counterparts. Second, use of DOAC therapy was also lowest among Black as compared to White patients. Third, the risk of bleeding, stroke, and mortality were all higher among Black as compared to White patients. Hispanic patients were also at higher risk of stroke as compared to White patients. These data, within the context of a concerted quality improvement effort, demonstrate that dedicated interventions are needed to achieve pharmacoequity. While the high rate of OAC use generally is laudable, further work is needed to address issues of health system institutional racism (e.g., educational materials available only in English language, availability of specialists), clinician implicit bias (e.g., likelihood of offering DOAC vs. warfarin based on race/ethnicity), and medication cost.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: African Americans, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Embolism, Ethnic Groups, Hemorrhage, Hispanic Americans, Intracranial Hemorrhages, Ischemic Stroke, Patient Discharge, Quality Improvement, Secondary Prevention, Socioeconomic Factors, Stroke, Vascular Diseases, Warfarin
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