Frail patients less likely to receive certain blood thinners, despite recommendations
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Among patients with nonvalvular atrial fibrillation, those with frailty were less likely to receive an anticoagulant and, if anticoagulated, were more likely to receive warfarin than a direct oral anticoagulant, researchers reported.
The introduction of direct oral anticoagulants has increased anticoagulation rates but not resolved treatment gaps for frail patients with nonvalvular AF, according to the researchers.
“Although they stand to potentially derive greater benefits from anticoagulation, frail patients with nonvalvular AF who didn’t have anticoagulant contraindications were 40% less likely to receive an anticoagulant and, even if anticoagulated, they were nearly 50% more likely to receive warfarin rather than a direct oral anticoagulant,” Finlay A. McAlister, MD, MSc, professor in the division of general internal medicine at the University of Alberta, Canada, told Healio. “The introduction of direct oral anticoagulants has increased anticoagulation rates but not resolved treatment gaps for frail patients with nonvalvular AF as anticoagulant prescribing in patients with guideline indications increased more in nonfrail patients (from 42% to 68%) than in frail patients (from 29% to 52%).”
In a retrospective study, McAlister and colleagues analyzed data from all adults discharged from an ED or hospital with a new diagnosis of nonvalvular AF from April 2009 to March 2019 in Alberta, Canada (n = 75,796; median age, 75 years; 45% women). Researchers used the Hospital Frailty Risk Score to define frailty and the CHA2DS2-VASc and CHADS-65 scores to identify whether anticoagulation was indicated.
Ongoing treatment gaps
Within the cohort, 22.6% of patients met the definition of frailty.
Researchers found that guideline criteria for anticoagulation were more commonly met by frail vs. nonfrail patients, both when using the CHA2DS2-VASc score (92.1% vs. 74.2%; P < .0001) and the CHADS-65 score (96.8% vs. 85.8%; P < .0001). However, frail patients were less likely to receive any anticoagulant, even after those with contraindications to anticoagulation were excluded (adjusted OR = 0.61; 95% CI, 0.58-0.64). After direct oral anticoagulants became available, anticoagulant prescribing for patients with guideline indications increased more among nonfrail patients (from 42.4% to 68.2%) than among frail patients (from 29% to 52.2%). Frail patients were less likely to receive a direct oral anticoagulant than warfarin (aOR = 0.66; 95% CI, 0.54-0.81).
“We encourage clinicians to evaluate absolute risks and benefits when making prescribing decisions,” McAlister told Healio. “We also encourage educators and those responsible for the dissemination of guidelines to focus attention on these ongoing treatment gaps in frail patients with nonvalvular AF, as the assumption that the arrival of [direct oral anticoagulants] would resolve these gaps is wrong, given our findings.”
McAlister said randomized controlled trials enrolling patients with frailty could increase clinician comfort regarding the safety and efficacy of direct oral anticoagulants in that population.
“We also need implementation science research to address the why we have these treatment gaps and develop active strategies to address them,” McAlister said.
‘Wake-up call’ for clinicians
In a related editorial, Lorne J. Gula, MD, and Allen C. Skanes, MD, of the London Heart Rhythm Program at Western University London in Ontario, Canada, wrote that the findings are “a wake-up call for clinicians on several fronts.”
“The explanations for these findings are undoubtedly multifactorial and complicated, possibly related as much to the opinions of those filling the prescriptions as those writing them,” Gula and Skanes wrote. “It is getting late in the game to consider direct oral anticoagulants an innovation, yet we seem stuck in the ‘early majority’ stage of their uptake. Even more shocking, we may be languishing in the same stage when considering anticoagulation in general for at-risk patients with AF. Orlandi et al remind us that there remains considerable work to be done to prod us forward to the ‘late majority’ stage of accepting direct oral anticoagulant therapy for prevention of AF stroke.”
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For more information:
Finlay A. McAlister, MD, MSc, can be reached at finlay.mcalister@ualberta.ca.
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