DOACs for Atrial Fibrillation, Why Are So Many AF Patients NOT on Anticoagulation? David Garcia, MD April 2017

Transcription

1 DOACs for Atrial Fibrillation, Why Are So Many AF Patients NOT on Anticoagulation? David Garcia, MD April 2017

2 Disclosures for David Garcia Consultancy: Boehringer Ingelheim; Bristol-Meyers Squibb; Daiichi Sankyo; Incyte; Pfizer Research Funding: Daiichi Sankyo; Incyte; Janssen Speakers Bureau: None Promotional Presentations: None Discussion of off-label drug use: None

3 AC is historically underutilized in patients with AF Circulation. 2014;129: Oldgren et al. Circulation Apr 15;129(15):

4 Why is AC Underutilized? Error of Omission vs. Commission AF is an asymptomatic risk factor AC is burdensome and/or expensive Risk-benefit decision is complex

5 CHADS 2 Score Correlates with Bleeding Risk in Elderly Poli et al. Thrombosis Research (2007) 121,

6 CHA 2 DS 2 VASc Score Correlates with Bleeding Risk Roldan et al. J Am Coll Cardiol Dec 10;62(23):

7 Can Doctors Predict Patients Preferences? Patients from 3 different primary care practices (none had AF) (n = 96) Internal medicine, family medicine, cardiology physicians (n = 96) Study set in Spain Various health states were described Major stroke, minor stroke, major bleeding and burden of treatment with warfarin

8 Probability Trade-off Scenario Alonso-Coello P, et al. Health Expectations, 18, pp

9 Who Participated Patients Physicians Alonso-Coello P, et al. Health Expectations, 18, pp

10 Number of GIBs acceptable in exchange for 3% reduction in stroke risk (per 100 pts over 2 years) Dark blue = patients Light blue = physicians Median acceptable # of GI Bleeds not different (10) Physicians whose pts had previously experienced a major bleed on warfarin or stroke without warfarin were willing to tolerate a higher number of bleeding events (15 16) Alonso-Coello P, et al. Health Expectations, 18, pp

11 ORBIT-AF : a U.S. Registry Data collected ambulatory care sites Primary care, cardiology, electrophysiology practices 9,553 patients with AF prior intracranial hemorrhage, allergy, and pregnancy, excluded (n = 89)

12 Proportion Taking an Anticoagulant All patients (n=9553) On Oral AC Not on Oral AC 78% 22% CHA 2 DS 2 VASc 2 (n = 8786) 79% 21% Hess et al. Am J Med Nov 23. pii: S (16) doi: /j.amjmed [Epub ahead of print]

13 Factors Associated with OAC Non-use Atrial fibrillation type (reference = new-onset) paroxysmal OR 0.73 persistent OR 0.35 permanent OR 0.14 left atrial enlargement (reference = normal diameter) mild OR 0.80 moderate OR 0.58 severe OR 0.53 Less likely to take OAC Less likely to take OAC Age >80 years OR 1.04 (per 1-year increase) Hess et al. Am J Med Nov 23. pii: S (16) doi: /j.amjmed [Epub ahead of print]

14 Other Factors that Decreased OAC Use History of coronary artery disease Alcohol abuse Cancer Hess et al. Am J Med Nov 23. pii: S (16) doi: /j.amjmed [Epub ahead of print]

15 ORBIT-AF Interpretation Perhaps some of these decisions not to anti-coagulate are appropriate One-fifth of the patients not treated with OAC had CHA 2 DS 2 VASc = 0 1 Increasing # of co-morbidities correlated with less OAC use This study likely over-estimates the proportion of AF patients on OAC Included sites may not be representative of general practice Possible Hawthorne Effect

16 Are DOACs Increasing the Proportion of AF Patients on Treatment? Alamneh et al. Am J Cardiovasc Drugs (2016) 16:

17 Office Visits for AF with Anticoagulant Use Barnes et al. Am J Med Dec; 128(12): e2

18 Quarterly Office Visits by AC Type Barnes et al. Am J Med Dec; 128(12): e2

19 Conclusion In the United States, it appears that many (though certainly not all) AF patients who stand to benefit from AC are receiving it. The arrival of the DOACs may have increased the overall proportion of AF patients on AC. The reasons for AC non-use among AF patients are complex (and sometimes legitimate)