It is relatively uncommon for patients with atrial fibrillation (AFib) taking warfarin who are eligible to switch to a direct oral anticoagulant (DOAC) to do so, with about one in six switching to a DOAC between 2010 and 2016, according to a study published May 6 in Clinical Cardiology.

Christopher T. Sciria, MD, et al., used data from ACC and Veradigm's PINNACLE Registry to examine patterns of anticoagulation among AFib patients receiving warfarin and determine predictors of switching to DOACs. The researchers also looked at potential disparities in care based on socioeconomic and clinical factors, including practice-level variations. Patients were stratified into three groups: those who continued warfarin, switched to a DOAC and discontinued anticoagulation.

Of 383,008 AFib patients initially taking warfarin, 68.8% continued warfarin, 16.3% switched to DOACs and 14.8% discontinued anticoagulation therapy. Patients who switched to DOACs were more likely to be younger, women, white, be treated by an electrophysiologist and have private insurance. Among patients switching to DOACs, 36.6% received dabigatran, 37% rivaroxaban, 24.4% apixaban and 1% edoxaban. Patients with an increased stroke risk, based on CHA2DS2-VASc scores, were less likely to switch to DOACs. Those with an increased bleeding risk, based on HAS-BLED scores, were more likely to switch to DOACs. In addition, the proportion of patients switching to DOACs increased over time, with 13.8% switching between 2010 to 2011, 34.2% between 2012 to 2013 and 52% between 2014 and 2016.

The study also found substantial practice-level variations, as well as variations among providers within the same practice. Practices with higher clinic volumes, more electrophysiologists and those located in the west were more likely to switch patients to DOACs.

According to the researchers, the relatively low rate of switching to DOACs and the high degree of practice-level variations suggest a standardized approach to switching patients from warfarin to DOACs is lacking. The findings benchmark performance and identify the need for performance improvement efforts to "better align care with practice guidelines," which favor DOACs over warfarin, they conclude.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Warfarin, Atrial Fibrillation, Benchmarking, Pyridones, Pyrazoles, Pyridines, Thiazoles, Anticoagulants, Registries, Cardiology, Socioeconomic Factors, National Cardiovascular Data Registries, PINNACLE Registry

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