Contemporary Trends in Oral Anticoagulant Prescription in Atrial Fibrillation Patients at Low to Moderate Risk of Stroke After Guideline-Recommended Change in Use of the CHADS2 to the CHA2DS2-VASc Score for Thromboembolic Risk Assessment: Analysis From the National Cardiovascular Data Registry's Outpatient Practice Innovation and Clinical Excellence Atrial Fibrillation Registry

David F Katz; Thomas M Maddox; Mintu Turakhia; Anil Gehi; Emily C O'Brien; Steven A Lubitz; Alexander Turchin; Gheorghe Doros; Lanyu Lei; Paul Varosy; Lucas Marzec; Jonathan C Hsu

doi:10.1161/CIRCOUTCOMES.116.003476

Contemporary Trends in Oral Anticoagulant Prescription in Atrial Fibrillation Patients at Low to Moderate Risk of Stroke After Guideline-Recommended Change in Use of the CHADS₂ to the CHA₂DS₂-VASc Score for Thromboembolic Risk Assessment: Analysis From the National Cardiovascular Data Registry's Outpatient Practice Innovation and Clinical Excellence Atrial Fibrillation Registry

Circ Cardiovasc Qual Outcomes. 2017 May;10(5):e003476. doi: 10.1161/CIRCOUTCOMES.116.003476.

Authors

Affiliations

¹ From the Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado School of Medicine, Denver (D.F.K., L.M.); Colorado Cardiovascular Outcomes Research Consortium, Denver (D.F.K., T.M.M., P.V., L.M.); Cardiology Section, VA Eastern Colorado Health Care System, Denver (T.M.M., P.V.); Section of Cardiac Electrophysiology, Division of Cardiology, Palo Alto VA Medical Center and Stanford University School of Medicine, CA (M.T.); Section of Cardiac Electrophysiology, Division of Cardiology, University of North Carolina, Chapel Hill (A.G.); Duke Clinical Research Institute, Durham, NC (E.C.O.); Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston (S.A.L.); Harvard Clinical Research Institute, Boston, MA (A.T., G.D., L.L.); Division of Endocrinology, Diabetes and Metabolism, Brigham and Women's Hospital, Boston, MA (A.T.); Harvard Medical School, Boston, MA (A.T.); Department of Biostatistics, Boston University, MA (G.D.); and Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla (J.C.H.).
² From the Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado School of Medicine, Denver (D.F.K., L.M.); Colorado Cardiovascular Outcomes Research Consortium, Denver (D.F.K., T.M.M., P.V., L.M.); Cardiology Section, VA Eastern Colorado Health Care System, Denver (T.M.M., P.V.); Section of Cardiac Electrophysiology, Division of Cardiology, Palo Alto VA Medical Center and Stanford University School of Medicine, CA (M.T.); Section of Cardiac Electrophysiology, Division of Cardiology, University of North Carolina, Chapel Hill (A.G.); Duke Clinical Research Institute, Durham, NC (E.C.O.); Cardiac Arrhythmia Service and Cardiovascular Research Center, Massachusetts General Hospital, Boston (S.A.L.); Harvard Clinical Research Institute, Boston, MA (A.T., G.D., L.L.); Division of Endocrinology, Diabetes and Metabolism, Brigham and Women's Hospital, Boston, MA (A.T.); Harvard Medical School, Boston, MA (A.T.); Department of Biostatistics, Boston University, MA (G.D.); and Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla (J.C.H.). Jonathan.Hsu@ucsd.edu.

PMID: 28506981
DOI: 10.1161/CIRCOUTCOMES.116.003476

Abstract

Background: Use of the CHA₂DS₂-VASc score instead of the CHADS₂ score for thromboembolic risk stratification and initiation of oral anticoagulation (OAC) was recommended in the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society atrial fibrillation (AF) guidelines. We sought to define the proportion of patients with AF qualifying for and receiving OAC in contemporary practice by applying the CHA₂DS₂-VASc score to patients with a low CHADS₂ score.

Methods and results: Among patients with AF enrolled in the American College of Cardiology National Cardiovascular Data Registry's outpatient Practice Innovation and Clinical Excellence registry (2008-2014) CHADS₂ score of 0 or 1, we calculated the impact of adoption of the CHA₂DS₂-VASc score on the proportion of patients with an indication for OAC. We examined trends in prescription of OAC overall, direct OAC (dabigatran/rivaroxaban/apixaban), and multivariable associations between clinical characteristics and OAC use. Of 346 068 patients with AF aged 65±12 years, 61% were men and 65% were white. In total, 24% of those with CHADS₂=0 and 81% of those with a CHADS₂=1 were reclassified as having a definite indication for OAC (CHA₂DS₂-VASc score ≥2). OAC use increased from 37% to 48% during the study period, and direct OAC use increased from 5% to 30%. Increasing CHA₂DS₂-VASc score (odds ratio, 2.07; 95% confidence interval, 1.97-2.19 for score of 4 versus 0) and rhythm control strategy (odds ratio, 1.34; 95% confidence interval, 1.30-1.39) were associated with increased OAC use.

Conclusions: Adoption of the CHA₂DS₂-VASc score reclassifies 64.5% of patients with AF with low CHADS₂ scores into a class I indication for OAC prescription. Overall OAC prescription increased between 2011 and 2014.

Keywords: anticoagulants; atrial fibrillation; stroke.

Publication types

Multicenter Study
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't

MeSH terms

Administration, Oral
Aged
Anticoagulants / administration & dosage*
Atrial Fibrillation / complications
Atrial Fibrillation / drug therapy*
Drug Prescriptions / statistics & numerical data*
Female
Guideline Adherence*
Humans
Male
Middle Aged
Outpatients / statistics & numerical data*
Prospective Studies
Registries
Risk Assessment
Risk Factors
Stroke / etiology
Stroke / prevention & control*
Thromboembolism / etiology
Thromboembolism / prevention & control*

Substances

Anticoagulants

Grants and funding

K23 HL114724/HL/NHLBI NIH HHS/United States