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Antithrombotic treatment gap among patients with atrial fibrillation and type 2 diabetes
Patrícia O Guimarães1, Eric D Peterson1, Susanna R Stevens1
1Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
Insights
Many patients with atrial fibrillation (AF), diabetes, and atherosclerotic cardiovascular disease (ASCVD) were undertreated with antithrombotic therapies. This highlights a gap in guideline adherence and potential for improved patient outcomes in managing these high-risk individuals.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Research
Background:
- The Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS) enrolled patients with type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD).
- A subset of TECOS participants had a history of atrial fibrillation (AF), a condition requiring careful antithrombotic management.
- Investigated antithrombotic therapy use in patients with AF, type 2 diabetes, and ASCVD.
Purpose of the Study:
- To evaluate the patterns of antithrombotic therapy use at baseline in patients with a history of AF, type 2 diabetes, and established ASCVD within the TECOS trial.
- To assess the association between AF history and clinical outcomes, including cardiovascular events and mortality.
Main Methods:
- Stratified TECOS participants with a history of AF by CHA2DS2-VASc score.
- Evaluated antithrombotic medication use (e.g., Vitamin K antagonists, aspirin, clopidogrel).
- Employed Cox proportional hazards models to analyze associations between AF and clinical outcomes, adjusting for baseline characteristics.
Main Results:
- Of 14,671 TECOS participants, 1167 (8%) had a history of AF.
- Antithrombotic use varied: 51.6% used Vitamin K antagonists (VKA), 56.8% used aspirin, and 7.3% used no antithrombotic medication.
- Patients with AF history showed increased risk for cardiovascular events, heart failure hospitalizations, and all-cause mortality compared to those without AF.
Conclusions:
- Nearly half of high-risk AF patients with diabetes and ASCVD in TECOS were not on recommended anticoagulation.
- This finding underscores a significant gap in guideline-recommended treatment for this patient population.
- There is a clear opportunity for clinical practice improvement in managing antithrombotic therapy for these patients.
Background:
We investigated the use of different antithrombotic therapies at baseline among patients with a history of atrial fibrillation (AF), type 2 diabetes, and established atherosclerotic cardiovascular disease (ASCVD) enrolled in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS).
Methods:
TECOS participants with a history of AF were stratified by CHA2DS2-VASc score and their antithrombotic use evaluated. Cox proportional hazards models were employed to explore possible associations between history of AF and prespecified clinical outcomes after adjusting for key baseline characteristics.
Results:
Of the 14,671 TECOS participants, 1167 (8%) had a history of AF, of whom 51.6% were using vitamin K antagonists (VKA); 31.2% used VKA alone, 16.9% used aspirin plus VKA, 1.8% used clopidogrel plus VKA, and 1.7% used aspirin and clopidogrel plus VKA. Aspirin was used by 56.8%: 30.9% used aspirin alone and 7.3% aspirin plus clopidogrel. Clopidogrel alone was used by 2.9%, and 7.3% were not using any antithrombotic medication. Participants with a history of AF had a higher risk of cardiovascular events, including hospitalization for heart failure and all-cause mortality, than those without AF. White, older men with prior myocardial infarction, heart failure, peripheral artery disease, or prior stroke were more likely to develop new-onset AF than others without these characteristics.
Conclusions:
Almost half of high-risk AF patients with diabetes and established ASCVD in TECOS were not treated with anticoagulation therapy despite clear guideline recommendations for such therapy, highlighting the challenge and potential for clinical improvements in managing these patients in clinical practice.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00790205.
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