Oral Anti-Coagulants Use in Chinese Hospitalized Patients with Atrial Fibrillation
Atrial fibrillation (AF) is the most prevalent arrhythmia worldwide and contributes significantly to morbidity and healthcare burden. In China, the prevalence of AF among individuals older than 45 years is estimated to be 1.8%, with approximately 8 million people affected. However, this number may be underestimated, as more than one-third of AF patients are unaware of their condition, and those with paroxysmal or asymptomatic manifestations may be underdiagnosed. AF is associated with a decreased quality of life, increased risks of heart failure, dementia, stroke, and death. Oral anticoagulants (OAC) are the only intervention for stroke prevention that consistently improves clinical outcomes and survival in AF patients. Despite this, OACs have been underutilized in China, particularly for stroke prevention in AF patients. This study aims to evaluate the utilization of OACs among hospitalized AF patients in China, identify trends over time, and explore factors associated with OAC use.
The study utilized data from the Improving Care for Cardiovascular Disease in China-Atrial Fibrillation (CCC-AF) registry, a nationwide quality improvement program launched in February 2015. The CCC-AF project aimed to improve cardiovascular health and outcomes in AF patients by optimizing adherence to guideline recommendations for AF treatment and management. The study enrolled 52,530 patients with non-valvular AF from 236 hospitals between February 2015 and December 2019. Patients with valvular AF or AF secondary to reversible conditions were excluded. The CHA2DS2-VASc score was used to stratify patients into high, moderate, and low stroke risk categories. Patients with a CHA2DS2-VASc score ≥2 in men or ≥3 in women were classified as high risk, those with a score of 1 in men or 2 in women as moderate risk, and those with a score of 0 in men or 1 in women as low risk.
The study found that 72.7% (38,203/52,530) of the enrolled patients were at high risk of stroke, 18.5% (9717/52,530) at moderate risk, and 8.8% (4610/52,530) at low risk. On admission, only 20.0% (6075/30,420) of patients with a diagnosed AF and high stroke risk were taking OACs. Pre-hospital OAC use was associated with a lower risk of new-onset ischemic stroke/transient ischemic attack (TIA) among the diagnosed AF population (adjusted odds ratio [aOR]: 0.54, 95% confidence interval [CI]: 0.43–0.68; P <0.001). At discharge, the prescription rate of OACs was 45.2% (16,757/37,087) in eligible patients with high stroke risk and 60.7% (2778/4578) in eligible patients with low stroke risk. OAC utilization in patients with high stroke risk on admission or at discharge increased significantly over time (all P <0.001).
Multivariate analysis revealed that OAC utilization at discharge was positively associated with in-hospital rhythm control strategies, including catheter ablation (aOR: 11.63, 95% CI: 10.04–13.47; P <0.001), electronic cardioversion (aOR: 2.41, 95% CI: 1.65–3.51; P <0.001), and anti-arrhythmic drug use (aOR: 1.45, 95% CI: 1.38–1.53; P <0.001). The study also found that OAC prescription rates varied widely among hospitals, with tertiary hospitals having higher prescription rates than secondary hospitals. In tertiary hospitals, the OAC prescription rate at discharge was 46.5% (IQR, 22.0%–64.8%) for patients with high stroke risk and 50.0% (IQR, 25.0%–69.0%) for patients with low stroke risk. In secondary hospitals, the rates were 23.0% (IQR, 12.0%–47.0%) and 21.0% (IQR, 0–50.0%), respectively.
The study identified several factors associated with OAC use at discharge. In patients with high stroke risk, in-hospital catheter ablation, electronic cardioversion, anti-arrhythmic drug use, persistent AF, and treatment in tertiary hospitals were associated with higher odds of OAC prescription. Conversely, age ≥75 years, a medical history of heart failure, long-standing or permanent AF, and concomitant antiplatelet use at discharge were associated with lower OAC prescriptions. Among patients with low stroke risk, in-hospital catheter ablation, anti-arrhythmic drug use, persistent AF, and treatment in tertiary hospitals were associated with higher OAC prescription rates, while concomitant antiplatelet use at discharge was associated with lower rates.
The study also examined contraindications to OAC use in patients with high stroke risk. Among patients who did not take OACs at discharge, 5.2% (1116/21,446) had strict contraindications, such as allergy, recent operations, active bleeding, and severe hepatic or renal comorbidities. However, 55.9% (11,993/21,446) had some or any documented contraindication at discharge. The most common documented contraindications were patient refusal (30.7%, 4319/14,086), inability to adhere/monitor (19.1%, 2696/14,086), and physician preference (15.8%, 2223/14,086). The proportion of patients unable to adhere/monitor decreased over time, from 29.8% (573/1921) in 2015 to 13.5% (563/4185) in 2019.
The study highlights the progress made in stroke prevention among the Chinese AF population through the CCC-AF project. Despite the poor performance on guideline adherence to OAC use, the project has seen significant improvements over time. The OAC prescribing rate at discharge increased from 35.1% in 2015 to 50.1% in 2019 for patients with high stroke risk. Similarly, the pre-hospital OAC utilization rate increased from 12.4% in 2015 to 29.3% in 2019. The study also found that OAC use was independently associated with in-hospital catheter ablation, electronic cardioversion, and anti-arrhythmic drug use.
In conclusion, the study demonstrates that over 70% of AF patients in the CCC-AF project were at high risk of stroke. Although OAC utilization remains suboptimal, the CCC-AF project has made substantial progress in improving stroke prevention in the Chinese AF population. The findings underscore the need for continued efforts to improve guideline adherence, particularly in addressing physician and patient-related barriers to OAC use.
doi.org/10.1097/CM9.0000000000002915
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