Evolving antithrombotic treatment patterns for patients with newly diagnosed atrial fibrillation

A John Camm, Gabriele Accetta, Giuseppe Ambrosio, Dan Atar, Jean-Pierre Bassand, Eivind Berge, Frank Cools, David A Fitzmaurice, Samuel Z Goldhaber, Shinya Goto, Sylvia Haas, Gloria Kayani, Yukihiro Koretsune, Lorenzo G Mantovani, Frank Misselwitz, Seil Oh, Alexander G G Turpie, Freek W A Verheugt, Ajay K Kakkar
Heart. 2016-09-19; 103(4): 307-314
DOI: 10.1136/HEARTJNL-2016-309832

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1. Heart. 2017 Feb 15;103(4):307-314. doi: 10.1136/heartjnl-2016-309832. Epub 2016
Sep 19.

Evolving antithrombotic treatment patterns for patients with newly diagnosed
atrial fibrillation.

Camm AJ(1), Accetta G(2), Ambrosio G(3), Atar D(4)(5), Bassand JP(6), Berge E(7),
Cools F(8), Fitzmaurice DA(9), Goldhaber SZ(10), Goto S(11), Haas S(12), Kayani
G(2), Koretsune Y(13), Mantovani LG(14), Misselwitz F(15), Oh S(16), Turpie
AG(17), Verheugt FW(18), Kakkar AK(2)(19); GARFIELD-AF Investigators.

Author information:
(1)Division of Cardiovascular Sciences, St George’s University of London, London,
UK.
(2)Thrombosis Research Institute, London, UK.
(3)Division of Cardiology, University of Perugia School of Medicine, Perugia,
Italy.
(4)Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.
(5)Faculty of Medicine, University of Oslo, Oslo, Norway.
(6)Department of Cardiology, EA 3920, University of Besançon, Besançon, France.
(7)Department of Internal Medicine, Oslo University Hospital, Oslo, Norway.
(8)AZ Klina, Brasschaat, Belgium.
(9)Department of Primary Care Clinical Sciences, University of Birmingham,
Birmingham, UK.
(10)Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard
Medical School, Boston, USA.
(11)Department of Medicine (Cardiology), Tokai University School of Medicine,
Isehara, Japan.
(12)Formerly Haemostasis and Thrombosis Research Group, Institute for
Experimental Oncology and Therapy Research, Technical University Munich, Munich,
Germany.
(13)Institute for Clinical Research, National Hospital Organization, Osaka
National Hospital, Osaka, Japan.
(14)Center for Public Health Research (CESP), University of Milano-Bicocca,
Milan, Italy.
(15)Bayer HealthCare Pharmaceuticals, Berlin, Germany.
(16)Department of Internal Medicine, Seoul National University Hospital, Seoul,
Korea.
(17)Department of Medicine, McMaster University, Hamilton, Canada.
(18)Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The
Netherlands.
(19)Department of Surgery, University College London, London, UK.

OBJECTIVE: We studied evolving antithrombotic therapy patterns in patients with
newly diagnosed non-valvular atrial fibrillation (AF) and ≥1 additional stroke
risk factor between 2010 and 2015.
METHODS: 39 670 patients were prospectively enrolled in four sequential cohorts
in the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation
(GARFIELD-AF): cohort C1 (2010-2011), n=5500; C2 (2011-2013), n=11 662; C3
(2013-2014), n=11 462; C4 (2014-2015), n=11 046. Baseline characteristics and
antithrombotic therapy initiated at diagnosis were analysed by cohort.
RESULTS: Baseline characteristics were similar across cohorts. Median
CHA2DS2-VASc (cardiac failure, hypertension, age ≥75 (doubled), diabetes, stroke
(doubled)-vascular disease, age 65-74 and sex category (female)) score was 3 in
all four cohorts. From C1 to C4, the proportion of patients on anticoagulant (AC)
therapy increased by almost 15% (C1 57.4%; C4 71.1%). Use of vitamin K antagonist
(VKA)±antiplatelet (AP) (C1 53.2%; C4 34.0%) and AP monotherapy (C1 30.2%; C4
16.6%) declined, while use of non-VKA oral ACs (NOACs)±AP increased (C1 4.2%; C4
37.0%). Most CHA2DS2-VASc ≥2 patients received AC, and this proportion increased
over time, largely driven by NOAC prescribing. NOACs were more frequently
prescribed than VKAs in men, the elderly, patients of Asian ethnicity, those with
dementia, or those using non-steroidal anti-inflammatory drugs, and current
smokers. VKA use was more common in patients with cardiac, vascular, or renal
comorbidities.
CONCLUSIONS: Since NOACs were introduced, there has been an increase in newly
diagnosed patients with AF at risk of stroke receiving guideline-recommended
therapy, predominantly driven by increased use of NOACs and reduced use of VKA±AP
or AP alone.
TRIAL REGISTRATION NUMBER: NCT01090362; Pre-results.

Published by the BMJ Publishing Group Limited. For permission to use (where not
already granted under a licence) please go to
http://www.bmj.com/company/products-services/rights-and-licensing/.

DOI: 10.1136/heartjnl-2016-309832
PMCID: PMC5293840
PMID: 27647168 [Indexed for MEDLINE]

Conflict of interest statement: AJC: advisor to Bayer, Boehringer Ingelheim,
Pfizer/BMS, and Daiichi Sankyo. GAm: advisor to Merck, Menarini, and Angelini.
DA: personal fees from Bayer Healthcare, BMS/Pfizer, Boehringer-Ingelheim, and
MSD. J-PB: personal fees from Aspen. FC: personal fees from Bayer, BMS, and
Boehringer-Ingelheim. DAF: personal fees from BMS/Pfizer, Boehringer-Ingelheim,
Daiichi Sankyo, and Bayer. SZG: grants from BiO2 Medical, Boehringer-Ingelheim,
Bristol Meyers Squibb, BTG EKOS, Daiichi Sankyo, National Heart Lung and Blood
Institute of the National Institutes of Health, Janssen, and Thrombosis Research
Group; personal fees from Bayer, Boehringer-Ingelheim, Bristol Meyers Squibb,
Daiichi Sankyo, Janssen, and Portola. SG: personal fees from the TRI, Bayer, and
AstraZeneca; grants from Sanofi and Pfizer. SH: personal fees from Aspen, Bayer
Healthcare, BMS/Pfizer, Daiichi-Sankyo, and Sanofi. YK: grants and personal fees
from Daiichi Sankyo and Boehringer-Ingelheim; personal fees from Bayer,
Bristol-Meyers Squibb, and Pfizer. LGM: grants and personal fees from Bayer
Healthcare and Pfizer; grants from Boehringer Ingelheim; personal fees from
Daiichi Sankyo. FM: employee of Bayer Pharma AG. SO: consultant/advisory board
payments from Bayer Pharma AG, Bristol-Myers Squibb Korea, Boehringer-Ingelheim
Korea, Pfizer Korea, Sanofi-Aventis, and St Jude Medical. AGGT: personal fees
from Bayer Healthcare, Janssen Pharmaceutical Research & Development LLC,
Astellas, Portola, and Takeda. FWAV: personal fees from Bayer Healthcare,
Daiichi-Sankyo, BMS/Pfizer, and Boehringer-Ingelheim. AKK: grants and personal
fees from Bayer Healthcare; personal fees from Boehringer-Ingelheim Pharma,
Daiichi Sankyo Europe, Sanofi SA, Janssen.

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