Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Original article

Vol. 147 No. 0506 (2017)

Uptake of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation – a prospective cohort study

DOI
https://doi.org/10.4414/smw.2017.14410
Cite this as:
Swiss Med Wkly. 2017;147:w14410
Published
09.02.2017

Summary

AIMS

We aimed to assess the uptake of non-vitamin K antagonist oral anticoagulants (NOACs) among patients with atrial fibrillation between 2010 and 2015 in Switzerland.

METHODS

We performed a prospective observational cohort study. At the baseline examination and during yearly follow-ups, we used questionnaires to obtain information about clinical characteristics and antithrombotic treatment. Stroke risk was assessed using the CHA2DS2-VASc score.

RESULTS

1545 patients were enrolled across seven centres in Switzerland. Mean age was 68 ± 12 years and 29.5% were female. The percentage of anticoagulated patients with an indication for oral anticoagulation (CHA2DS2-VASc score ≥2 in women and ≥1 in men) was 75% in 2010 and 80% in 2015 (p = 0.2). There was a gradual increase in the use of NOACs from 0% in 2010 to 29.8% in 2015 (p <0.0001). Out of 888 patients, who initially received a vitamin K antagonist (VKA), 86 (9.7%) were switched to an NOAC during follow-up. Use of aspirin as a monotherapy decreased from 23% in 2010 to 11% in 2015 (p <0.0001).

CONCLUSION

After regulatory approval, the use of NOACs in Switzerland steadily increased to about 30% in 2015, whereas switches from VKAs to NOACs were infrequent. In parallel, the prescription of aspirin as monotherapy was more than halved, suggesting significant guideline-concordant improvements in oral anticoagulation use among patients with atrial fibrillation.

References

  1. Krijthe BP, Kunst A, Benjamin EJ, Lip GY, Franco OH, Hofman A, et al. Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J. 2013;34(35):2746–51. doi:.https://doi.org/10.1093/eurheartj/eht280
  2. Conen D, Chae CU, Glynn RJ, Tedrow UB, Everett BM, Buring JE, et al. Risk of death and cardiovascular events in initially healthy women with new-onset atrial fibrillation. JAMA. 2011;305(20):2080–7. doi:.https://doi.org/10.1001/jama.2011.659
  3. Wang TJ, Larson MG, Levy D, Vasan RS, Leip EP, Wolf PA, et al. Temporal relations of atrial fibrillation and congestive heart failure and their joint influence on mortality: the Framingham Heart Study. Circulation. 2003;107(23):2920–5. doi:.https://doi.org/10.1161/01.CIR.0000072767.89944.6E
  4. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22(8):983–8. doi:.https://doi.org/10.1161/01.STR.22.8.983
  5. Kalantarian S, Stern TA, Mansour M, Ruskin JN. Cognitive impairment associated with atrial fibrillation: a meta-analysis. Ann Intern Med. 2013;158(5 Pt 1):338–46. doi:.https://doi.org/10.7326/0003-4819-158-5-201303050-00007
  6. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146(12):857–67. doi:.https://doi.org/10.7326/0003-4819-146-12-200706190-00007
  7. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al.; RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139–51. doi:.https://doi.org/10.1056/NEJMoa0905561
  8. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al.; ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981–92. doi:.https://doi.org/10.1056/NEJMoa1107039
  9. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al.; ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883–91. doi:.https://doi.org/10.1056/NEJMoa1009638
  10. Giugliano RP, Ruff CT, Braunwald E, Murphy SA, Wiviott SD, Halperin JL, et al.; ENGAGE AF-TIMI 48 Investigators. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2013;369(22):2093–104. doi:.https://doi.org/10.1056/NEJMoa1310907
  11. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al.; ESC Committee for Practice Guidelines-CPG; Document Reviewers. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation--developed with the special contribution of the European Heart Rhythm Association. Europace. 2012;14(10):1385–413. doi:.https://doi.org/10.1093/europace/eus305
  12. Desai NR, Krumme AA, Schneeweiss S, Shrank WH, Brill G, Pezalla EJ, et al. Patterns of initiation of oral anticoagulants in patients with atrial fibrillation- quality and cost implications. Am J Med. 2014;127(11):1075–82.e1. doi:.https://doi.org/10.1016/j.amjmed.2014.05.013
  13. Connolly SJ, Eikelboom J, Joyner C, Diener HC, Hart R, Golitsyn S, et al.; AVERROES Steering Committee and Investigators. Apixaban in patients with atrial fibrillation. N Engl J Med. 2011;364(9):806–17. doi:.https://doi.org/10.1056/NEJMoa1007432
  14. Alamneh EA, Chalmers L, Bereznicki LR. Suboptimal Use of Oral Anticoagulants in Atrial Fibrillation: Has the Introduction of Direct Oral Anticoagulants Improved Prescribing Practices? Am J Cardiovasc Drugs. 2016;16(3):183–200. doi:.https://doi.org/10.1007/s40256-016-0161-8
  15. Berti D, Moors E, Moons P, Heidbuchel H. Prevalence and antithrombotic management of atrial fibrillation in hospitalised patients. Heart. 2015;101(11):884–93. doi:.https://doi.org/10.1136/heartjnl-2014-307059
  16. Kirley K, Qato DM, Kornfield R, Stafford RS, Alexander GC. National trends in oral anticoagulant use in the United States, 2007 to 2011. Circ Cardiovasc Qual Outcomes. 2012;5(5):615–21. doi:.https://doi.org/10.1161/CIRCOUTCOMES.112.967299
  17. Steinberg BA, Holmes DN, Piccini JP, Ansell J, Chang P, Fonarow GC, et al.; Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) Investigators and Patients. Early adoption of dabigatran and its dosing in US patients with atrial fibrillation: results from the outcomes registry for better informed treatment of atrial fibrillation. J Am Heart Assoc. 2013;2(6):e000535. doi:.https://doi.org/10.1161/JAHA.113.000535
  18. Barnes GD, Lucas E, Alexander GC, Goldberger ZD. National Trends in Ambulatory Oral Anticoagulant Use. Am J Med. 2015;128(12):1300–5.e2. doi:.https://doi.org/10.1016/j.amjmed.2015.05.044
  19. Kirchhof P, Ammentorp B, Darius H, De Caterina R, Le Heuzey JY, Schilling RJ, et al. Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention oF thromboemolic events--European Registry in Atrial Fibrillation (PREFER in AF). Europace. 2014;16(1):6–14. doi:.https://doi.org/10.1093/europace/eut263
  20. Le Heuzey JY, Ammentorp B, Darius H, De Caterina R, Schilling RJ, Schmitt J, et al. Differences among western European countries in anticoagulation management of atrial fibrillation. Data from the PREFER IN AF registry. Thromb Haemost. 2014;111(5):833–41. doi:.https://doi.org/10.1160/TH13-12-1007
  21. Huisman MV, Rothman KJ, Paquette M, Teutsch C, Diener HC, Dubner SJ, et al.; GLORIA-AF Investigators. Antithrombotic Treatment Patterns in Patients with Newly Diagnosed Nonvalvular Atrial Fibrillation: The GLORIA-AF Registry, Phase II. Am J Med. 2015;128(12):1306–13.e1. doi:.https://doi.org/10.1016/j.amjmed.2015.07.013
  22. Flaker GC, Eikelboom JW, Shestakovska O, Connolly SJ, Kaatz S, Budaj A, et al. Bleeding during treatment with aspirin versus apixaban in patients with atrial fibrillation unsuitable for warfarin: the apixaban versus acetylsalicylic acid to prevent stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment (AVERROES) trial. Stroke. 2012;43(12):3291–7. doi:.https://doi.org/10.1161/STROKEAHA.112.664144
  23. Hsu JC, Maddox TM, Kennedy KF, Katz DF, Marzec LN, Lubitz SA, et al. Oral anticoagulant therapy prescription in patients with atrial fibrillation across the spectrum of stroke risk: Insights from the ncdr pinnacle registry. JAMA Cardiol. 2016;1(1):55–62. doi:.https://doi.org/10.1001/jamacardio.2015.0374
  24. January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, Jr, et al.; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64(21):e1–76. doi:.. Erratum in: J Am Coll Cardiol. 2014 Dec 2;64(21):2305–7. https://doi.org/10.1016/j.jacc.2014.03.022
  25. Guimarães PO, Kaatz S, Lopes RD. Practical and clinical considerations in assessing patients with atrial fibrillation for switching to non-vitamin K antagonist oral anticoagulants in primary care. Int J Gen Med. 2015;8:283–91.
  26. Verdecchia P, Angeli F, Aita A, Bartolini C, Reboldi G. Why switch from warfarin to NOACs? Intern Emerg Med. 2016;11(3):289–93. doi:.https://doi.org/10.1007/s11739-016-1411-0
  27. Bouillon K, Bertrand M, Maura G, Blotière PO, Ricordeau P, Zureik M. Risk of bleeding and arterial thromboembolism in patients with non-valvular atrial fibrillation either maintained on a vitamin K antagonist or switched to a non-vitamin K-antagonist oral anticoagulant: a retrospective, matched-cohort study. Lancet Haematol. 2015;2(4):e150–9. doi:.https://doi.org/10.1016/S2352-3026(15)00027-7
  28. Lip GY. Recommendations for thromboprophylaxis in the 2012 focused update of the ESC guidelines on atrial fibrillation: a commentary. J Thromb Haemost. 2013;11(4):615–26. doi:.https://doi.org/10.1111/jth.12140