The use of novel oral anticoagulants in patients with atrial fibrillation is low in Europe, and compliance with European treatment guidelines for AF is suboptimal in those at the lowest and highest risk for stroke, according to a report by the European Society of Cardiology.
The ESC conducted the EuroObservational Research Programme Atrial Fibrillation (EORP-AF) registry of more than 3,000 inpatients and outpatients with AF (mean age, 68 years; 40.4% women) who presented to cardiologists in nine participating ESC countries from February 2012 to March 2013. The goal was to collect contemporary data on management and treatment of AF in member countries.
Hypertension (70.9%), coronary disease (63.5%) and HF topped the list of common comorbidities among patients in the registry. Previous stroke was reported in 6.4% of patients and chronic kidney disease in 13.2%. Only 3.9% of patients had cardiologist-defined lone AF.
Clinical types of AF were as follows: first-detected, 30.3%; paroxysmal, 26.5%; persistent, 21.2%; long-standing persistent, 4.8%; and permanent, 17.3%. Asymptomatic AF was common, especially in those with permanent AF, according to the report.
Antiarrhythmic drugs most often prescribed included amiodarone (21.5%), propafenone (5.3%) and flecainide (5%).
Oral anticoagulants were used in approximately 80% of patients, most often vitamin K antagonists (71.6%).
Novel oral anticoagulant use low
Novel oral anticoagulants were used in 8.4% of patients. Dabigatran (Pradaxa, Boehringer Ingelheim) was used in 6.8%, rivaroxaban (Xarelto, Janssen Pharmaceuticals) in 1.6% and apixaban (Eliquis, Bristol-Myers Squibb/Pfizer) in 0%.
Aspirin was used in 30.7% of patients. An oral anticoagulant plus one antiplatelet was used in 16.4% of patients, and an oral anticoagulant plus two antiplatelets was used in 3.7% of patients.
Of rate-control agents, beta-blockers were prescribed in 69.2% of patients, digoxin was used in 19.4% and non-dihydropyridine calcium-channel blockers were used in 6.2%. Combination therapy consisting of a beta-blocker and digoxin was used in 15% of patients and combination therapy consisting of a non-dihydropyridine calcium-channel blocker and digoxin was used in 1.1% of patients.
The mean CHA2DS2-VASc score was 3.2 and mean HAS-BLED score was 1.4, with the highest risk seen in patients with long-standing persistent AF and permanent AF.
In each CHA2DS2-VASc score between 2 and 8, at least 78% of patients used oral anticoagulants. In those with a CHA2DS2-VASc score of 9, the highest risk for stroke, 66.7% used oral anticoagulants and the rest used other antithrombotic drugs, most often antiplatelet therapy. According to the authors of the report, ESC guidelines recommend oral anticoagulants for these patients because “aspirin is minimally effective for stroke prevention and may not be any safer.”
Lowest-risk patients still receive anticoagulation
In patients with a CHA2DS2-VASc score of 0, 56.4% used oral anticoagulants, 16.8% received other antithrombotic drugs and 26.3% had no antithrombotic therapy. Approximately half of those with a CHA2DS2-VASc score of 0 prescribed an oral anticoagulant were scheduled for cardioversion. The ESC guidelines recommend no antithrombotic therapy for those with a CHA2DS2-VASc score of 0, according to the authors.
Independent predictors of oral anticoagulant prescription included younger age, higher BMI, hyperthyroidism, prior stroke, high CHA2DS2-VASc score (although less in women), high systolic BP, high HAS-BLED score and chronic kidney disease. Hyperthyroidism is not a proven risk factor for stroke, but older data suggest that it might be in patients with AF, so “its presence seems to increase cardiologists’ use of [oral anticoagulants],” Gregory Y.H. Lip, MD, of the University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom, and colleagues wrote.
In each HAS-BLED score, at least 65% of patients received oral anticoagulants, but there was a trend toward more use of other antithrombotic drugs, most often antiplatelet therapy, in those with higher scores. Cardiologists “are supportive of the manner in which the HAS-BLED score is to be used as per the guidelines,” Lip and colleagues wrote.
Disclosure: The researchers report no relevant financial disclosures.