Journal Wrap

The hottest research from various peer-reviewed journals - handpicked weekly by the Editorial Board led by Kim Eagle, MD, MACC.

Regional Variation in Oral Anticoagulation Use in AFib Patients To Prevent Stroke

Use of oral anticoagulation (OAC) to prevent stroke in patients with atrial fibrillation (AFib) varies substantially by region, according to results of a study published in Stroke. This variation presented a similar geographic pattern to variation in stroke rates.

Researchers used claims data from a 5 percent random sample of Medicare beneficiaries to identify newly diagnosed AFib patients prescribed novel oral anticoagulants (NOACs) (n = 8,659), warfarin (n = 11,771) or no oral anticoagulation therapy (n = 18,226) from 2013 to 2014. Each patient was assigned to one of the 306 Dartmouth hospital-referral regions based on his/her zip code. Read More >>>

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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Do Reductions in Serum Cholesterol Impact Survival in FH Patients?

The extent of reduction of serum cholesterol achieved by a combination of lipid-lowering measures is a major determinant of survival in patients with homozygous familial hypercholesterolemia (FH), according to a study published in the European Heart Journal. Read More >>>

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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What Factors Most Affect Rhythm Control Treatment Decisions in Patients With AFib?

Rhythm control is a cornerstone of therapy for nonvalvular atrial fibrillation (AFib) and can significantly improve AFib symptoms. However, it may be underused in outpatient centers across the U.S., and there is substantial practice variation, according to a randomized clinical trial published in the American Heart Journal.

Anil K. Gehi, MD, et al., used data from ACC’s PINNACLE Registry to analyze treatment decisions for 511,958 patients diagnosed with nonvalvular AFib between May 1, 2008 and Dec. 31, 2014. Most patients were elderly (72 years) and white (62 percent) and had a variety of comorbidities and moderate-high CHADS2 (1.9 ± 1.3) and CHA2DS2-VASc (3.6 ± 1.8) scores. Read More >>>

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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Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Dyslipidemia, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Lipid Metabolism, Nonstatins, Primary Hyperlipidemia

Keywords: ACC Publications, Cardiology Magazine, Atrial Fibrillation, Research Personnel, Hyperlipoproteinemia Type II, Stroke, Anticoagulants, Medicare, Referral and Consultation, Lipids, Cholesterol

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