Racial, gender differences exist in AF care

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Outpatient care for atrial fibrillation differs based on race and gender, according to an analysis of Medicare patients who were diagnosed with atrial fibrillation in 2010 and 2011.

Lead researcher Prashant D. Bhave, MD, an electrophysiologist at the University of Iowa Hospitals and Clinics in Iowa City, and colleagues found that females were less likely than males to visit an electrophysiology specialist, receive an oral anticoagulant prescription or undergo catheter ablation.

Compared with white patients, black patients were less likely to have rate control and rhythm control and use anticoagulants and Hispanic patients were less likely to receive rhythm-controlling medications and catheter ablation. The findings were published online in HeartRhythm on July 1.

In the U.S., approximately 1 percent of the overall population and 5 percent of people 65 or older have atrial fibrillation, which is associated with an increase in stroke risk and mortality.

Bhave said patients with atrial fibrillation typically have severe strokes that cause more disability compared with patients who do not have the disease. He added that he was particularly concerned at the discrepancies in the prescribing rates for oral anticoagulants. Although the drugs cause bleeding in some patients, Bhave said the reduction of stroke risk in most patients is greater than the risk of bleeding.

During the study period, the only two oral anticoagulants available were warfarin and dabigatran (Pradaxa, Boehringer Ingelheim). Since then, the FDA has approved rivaroxaban (Xarelto, Bayer/Johnson & Johnson) and apixaban (Eliquis, Bristol-Myers Squibb).

“That’s the most telling thing from this study because [oral anticoagulants] are really a cornerstone of the care of afib and trying to prevent these devastating strokes from happening,” Bhave told Cardiovascular Business. “The decision of whether or not to put someone with afib on a blood thinner is predicated on their stroke risk, and part of your stroke risk is how old you are. This is a cohort of patients that are old, so they already have risk factors for stroke.”

Bhave et al examined databases from the Centers for Medicare & Medicaid Services and evaluated 517,941 patients who were diagnosed with atrial fibrillation in 2010 and 2011. Patients were excluded if they were younger than 66 when diagnosed, were enrolled in a Medicare managed care plan and were not enrolled in Medicare Part D during the month of their diagnosis.

Of the patients, 87 percent were white and 59 percent were female. Black patients were more likely than white patients to have comorbid conditions such as congestive heart failure, hypertension, diabetes, cerebrovascular disease and chronic kidney disease. There were fewer differences between male and female patients, although female patients had a higher mean CHADS2 stroke risk score.

During a mean follow-up period of 640 days, 85.5 percent of patients visited a general cardiologist, 71.6 percent received a rate-controlling medication, 46.5 percent received an oral anticoagulant, 24.6 percent received an antiarrhythmic drug, 20.8 percent visited an electrophysiologist and 1.5 percent underwent catheter ablation.

Bhave said a limitation of the study was that it only included older adults and did not evaluate anyone younger than 65. The researchers are hoping to gain access to state databases that include data on other patient demographics.

He also said the study could not determine why females and minorities were less likely to receive oral anticoagulants or other medications. However, he said previous studies showed women and minorities received less aggressive and suboptimal cardiovascular disease care, although the researchers in this study found the rates of referral to a heart rhythm specialist were equal among all patients.

“The issues are either that providers are less likely to prescribe more aggressive therapies or blood thinners to women or that women were less likely to want to have those procedures done or want to take those medications long-term,” Bhave said.