Deciding between novel oral anticoagulants and vitamin K antagonists in non-valvular atrial fibrillation in hospital practice: what matters?

Scope: Oral anticoagulation (OAC) is a landmark therapy in stroke prevention in non-valvular atrial fibrillation (AF), with Non-antivitamin K OAC (NOAC) being an effective and safer alternative to vitamin K antagonists (VKA). In clinical practice, the decision to choose between NOAC and VKA is based on multiple variables, which could be different from the guideline indications. The aim of this study was to identify the main factors taken into account by hospital physicians when deciding between NOAC and VKA.

Methods: Patients with AF admitted from January 2018 to June 2019 to a tertiary hospital in Bucharest/ Romania were included in this study. Valvular AF, in-hospital mortality, and readmissions were excluded. We assessed OAC indication at hospital discharge, after a shared decision process with the patients and their families. We evaluated as main variables: gender, age, heart failure (HF), ejection fraction (EF), ische-mic heart disease, estimated glomerular filtration rate (eGFR), anemia, thrombocytopenia, malignancy, cirrhosis, peptic ulcer and social characteristics.

Results: We included 724 consecutive AF patients. For 377 patients, VKA was prescribed and for 347 the prescription of choice was NOAC. The mean age for the two groups was similar, with 72.47 ± 9.92 years for VKA vs. 71.51 ± 10.82 years for NOAC. Mean CHA-2DS2-VASC and HASBLED scores were comparable in patients receiving NOACs and VKAs (3.39±1.42 vs 3.38±1.46, p=0.89, respectively 1.73±0.77 vs 1.64±0.77, p=0.12). NOACs were similary prescribed in both gen-ders (50.65% women vs. 44.58% in men, p=0.10). Pre-scribing patterns did not differ between living environ-ment: 46.76% of patients from urban areas were pre-scribed NOACs and 50.43% from rural areas (p=0.35). NOACs were more frequently prescribed in patients with paroxysmal (56.93%) and persistent AF (58.24%), compared to those with permanent AF (35.82%, p<0.001). Patients with heart failure were more fre-quently prescribed VKA (OR: 1.73, 95%CI 1.15-2.58, p=0.006), as were patients with eRFG < 30 ml/min (OR: 1.93, 95%CI 0.96-3.86, p=0.05) and anemia (OR:1.43, 95%CI 1.02-1.99, p=0.03). NOAC were prescribed more often to preserved ejection fraction (EF) patients (52.16%), followed by mid-range EF (40.5%, p=0.028) and reduced EF(40.76%, p=0.019). NOAC were prefe-rentially used in patients with concomitant stable an-gina (OR: 1.91, 95%CI 1.19-3.07, p=0.006). Diabetes, malignancy, cirrhosis, thrombocytopenia, history of peptic ulcer and emergency admission of the patient did not influence choosing between NOAC and VKA.

Conclusions: Almost 50% of the studied group were prescribed NOACs. Preserved EF, the presence of stable angina, paroxistic and persistent AF were associated with NOAC use, while anemia, reduced eRFG, reduced EF and permanent AF were associated with VKA use. In contemporary hospital practice, NOACs are increa-singly prescribed.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)