Oral anticoagulation use in non-valvular atrial fibrillation patients in rural setting

Area of Science:

• Cardiology
• Pharmacology
• Public Health

Background:

• The 2019 ACC/AHA/HRS guidelines recommended direct oral anticoagulants (DOACs) as the preferred first-line therapy over warfarin for patients with non-valvular atrial fibrillation (AF).
• This shift aimed to improve anticoagulation management and reduce stroke risk in AF patients.

Purpose of the Study:

• To evaluate the impact of the 2019 guidelines on the adoption of DOACs versus warfarin in a real-world ambulatory setting.
• To identify patient characteristics and provider-reported barriers influencing oral anticoagulation (OAC) prescription patterns.

Main Methods:

• A retrospective analysis of 12,014 ambulatory patients with non-valvular AF or atrial flutter between October 2019 and July 2020.
• Patients were categorized by OAC type (warfarin, DOAC, or no OAC). High-risk AF was defined by CHA₂DS₂-VASc scores. Provider knowledge and barriers were assessed via a REDCap survey.

Main Results:

• Despite guideline changes, overall OAC use remained stable (75.6% vs. 75.7%). Warfarin use decreased by 2.3%, while DOAC use increased by 2.4% (p<0.001).
• Factors increasing OAC prescription included age, male gender, higher CHA₂DS₂-VASc scores, hypertension, and prior stroke. Factors decreasing OAC use included vascular disease, high ATRIA bleed scores, renal disease, prior hemorrhage, and left atrial appendage occlusion.
• Provider surveys identified bleeding risk (35.1%) and cost (25.0%) as primary barriers to DOAC use, particularly in rural populations.

Conclusions:

• The 2019 guidelines led to a modest increase in DOAC utilization for non-valvular AF patients.
• Significant barriers, including bleeding risk perception and cost, impede widespread DOAC adoption, especially in rural settings.
• A substantial proportion of high-risk AF patients remain without optimal anticoagulation therapy, highlighting a gap in care delivery.