DOACs underprescribed among high-risk AFib patients

Direct oral anticoagulants (DOACs) aren’t prescribed to frail atrial fibrillation (AFib) patients as much as they should be, according to a new study published in the Canadian Journal of Cardiology.

In the analysis, researchers point out that blood clots related to AFib can be prevented with DOACs, which have a better safety profile than warfarin.

“We were curious if the introduction of DOACs would help to address the known care gap that frail people with AFib are less likely to be prescribed anticoagulant drugs like warfarin, because they have more trouble going to the lab frequently for blood work and are at higher risk for bleeding complications,” lead investigator Finlay A. McAlister, MD, MSc, with the department of medicine at the University of Alberta, said in a prepared statement.

The group examined prescribing data for 75,796 adults who were released from an emergency department or hospital with a new diagnosis of nonvalvular AFib between April 2009 and March 2019.

After evaluating each patient's Hospital Frailty Risk Score, the authors found that more than 17,000 patients qualified as being frail. Seventy-six percent of those patients were elderly 65 years old or older.

The majority of patients also met Canadian guidelines for anticoagulation treatment. This included 92.1% of frail patients and 74.2% of non-frail patients. Anticoagulants were much more likely to be prescribed to non-frail patients than frail patients. Moreover, frail patients who did receive a prescription for anticoagulants were 34% less likely to be prescribed a DOAC than warfarin.

The authors did note that DOACs are relatively new, so some physicians may have been moving slow with their prescriptions. However, McAllister pointed out in the same statement, the proportion of patients who have nonvalvular AFib is rising, and there has been a widespread assumption that the treatment disparity in frail patients would have improved since the introduction of DOACs.

“Our data demonstrate this is a misconception,” he said. “We shouldn’t assume that new therapies will be taken up by clinicians in the way we expect them to. As frail patients have higher event rates and thus stand to potentially derive greater benefit from anticoagulation than their non-frail counterparts, we encourage clinicians to evaluate absolute risks and benefits when making prescribing decisions.”

Read the full study here

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