Regardless of clinical and socioeconomic factors, black patients with atrial fibrillation (AF) are significantly less likely than whites and Hispanics to receive appropriate treatment with oral anticoagulants (OACs), researchers reported Nov. 28 in JAMA Cardiology.
Black and Hispanic communities typically see a lower prevalence of AF compared to white areas, first author Utibe R. Essien, MD, MPH, and colleagues wrote in the journal, but blacks face a higher risk of stroke than whites and Hispanics see poorer AF outcomes. Long-term treatment with OACs or direct-acting OACs (DOACs) is often recommended to reduce the stroke risk associated with AF.
“Prior studies have shown that anticoagulation use in underrepresented ethnic groups with AF is lower than in white individuals, with some of this disparity explained by socioeconomic status,” Essien, an assistant professor of medicine at the University of Pittsburgh, et al. wrote. “Time in the therapeutic range of international normalized ratio of 2.0 to 3.0 on warfarin, a measure of anticoagulation quality, has also been shown to be lower in black patients compared with white patients, as well as in patients with limited English proficiency, increasing the stroke risk in these populations.”
Those studies didn’t assess DOACs, though, the authors said, so they launched their own review of data from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II (ORBIT-AF II) in an attempt to identify any persistent racial disparities in OAC use for patients with AF.
The researchers looked at 12,417 AF patients in total, 88.6 percent of whom were white, 5.2 percent of whom were black and 5.4 percent of whom were Hispanic. Race was self-reported and the team used info from the ORBIT-AF II database to quantify OAC and DOAC use and quality.
After adjustment for clinical characteristics, the authors found blacks were 25 percent less likely than whites or Hispanics to receive any treatment with OACs. Further, they were 37 percent less likely to receive DOACs if an anticoagulant was prescribed, and DOAC use as a whole was significantly lower in black patients. Utibe et al. didn’t note much of a difference in OAC or DOAC use between white and Hispanic patients.
“Black patients with AF were less likely to receive DOACs, which are easier to use than warfarin and likely safer,” they wrote. “Recent evidence has shown that medication adherence is higher for DOACs than for warfarin. This increase in adherence to DOACs over warfarin may serve as a way to improve anticoagulant treatment in racial/ethnic minority patients with AF.”
The authors’ analysis also revealed that blacks and Hispanics treated with DOACs were more likely to receive inappropriate dosing than whites. They said one-year persistence on OACs was the same across all three groups.
Clyde W. Yancy, MD, MSc, the deputy editor of JAMA Cardiology, said in an editor’s note that Utibe et al.’s work underscores the importance of addressing the racial gap in cardiovascular care.
“All of us physicians and all our patients engage the healthcare experience with biases that emanate from deep and firmly embedded life experiences,” Yancy wrote. “The goal is not to rewire culture, but to change context. Falling short exposes our patients to untoward outcomes; in the ORBIT-AF II trial, this is an unprotected vulnerability to stroke.”