Evolving Changes of the Use of Oral Anticoagulants and Outcomes in Patients With Newly Diagnosed Atrial Fibrillation in Taiwan
2018; Lippincott Williams & Wilkins; Volume: 138; Issue: 14 Linguagem: Inglês
10.1161/circulationaha.118.036046
ISSN1524-4539
AutoresTze‐Fan Chao, Chern-En Chiang, Yenn‐Jiang Lin, Shih‐Lin Chang, Li‐Wei Lo, Yu‐Feng Hu, Ta‐Chuan Tuan, Jo‐Nan Liao, Fa‐Po Chung, Tzeng‐Ji Chen, Gregory Y.H. Lip, Shih‐Ann Chen,
Tópico(s)Cardiac Arrhythmias and Treatments
ResumoHomeCirculationVol. 138, No. 14Evolving Changes of the Use of Oral Anticoagulants and Outcomes in Patients With Newly Diagnosed Atrial Fibrillation in Taiwan Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBEvolving Changes of the Use of Oral Anticoagulants and Outcomes in Patients With Newly Diagnosed Atrial Fibrillation in Taiwan Tze-Fan Chao, MD, Chern-En Chiang, MD, Yenn-Jiang Lin, MD, Shih-Lin Chang, MD, Li-Wei Lo, MD, Yu-Feng Hu, MD, Ta-Chuan Tuan, MD, Jo-Nan Liao, MD, Fa-Po Chung, MD, Tzeng-Ji Chen, MD, Gregory Y.H. Lip, MD and Shih-Ann Chen, MD Tze-Fan ChaoTze-Fan Chao Division of Cardiology, Department of Medicine (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.), Taipei Veterans General Hospital, Taiwan. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.). , Chern-En ChiangChern-En Chiang Division of Cardiology, Department of Medicine (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.), Taipei Veterans General Hospital, Taiwan. General Clinical Research Center (C.-E.C.), Taipei Veterans General Hospital, Taiwan. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.). , Yenn-Jiang LinYenn-Jiang Lin Division of Cardiology, Department of Medicine (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.), Taipei Veterans General Hospital, Taiwan. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.). , Shih-Lin ChangShih-Lin Chang Division of Cardiology, Department of Medicine (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.), Taipei Veterans General Hospital, Taiwan. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.). , Li-Wei LoLi-Wei Lo Division of Cardiology, Department of Medicine (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.), Taipei Veterans General Hospital, Taiwan. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.). , Yu-Feng HuYu-Feng Hu Division of Cardiology, Department of Medicine (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.), Taipei Veterans General Hospital, Taiwan. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.). , Ta-Chuan TuanTa-Chuan Tuan Division of Cardiology, Department of Medicine (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.), Taipei Veterans General Hospital, Taiwan. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.). , Jo-Nan LiaoJo-Nan Liao Division of Cardiology, Department of Medicine (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.), Taipei Veterans General Hospital, Taiwan. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.). , Fa-Po ChungFa-Po Chung Division of Cardiology, Department of Medicine (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.), Taipei Veterans General Hospital, Taiwan. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.). , Tzeng-Ji ChenTzeng-Ji Chen Department of Family Medicine (T.-J.C.), Taipei Veterans General Hospital, Taiwan. , Gregory Y.H. LipGregory Y.H. Lip Gregory Y. H. Lip, MD, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom B18 7QH. E-mail Address: [email protected] Institute of Cardiovascular Sciences, University of Birmingham, United Kingdom (G.Y.H.L.). and Shih-Ann ChenShih-Ann Chen Shih-Ann Chen, MD, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd, Taipei, Taiwan 11217 Email E-mail Address: [email protected] Division of Cardiology, Department of Medicine (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.), Taipei Veterans General Hospital, Taiwan. Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan (T.-F.C., C.-E.C., Y.-J.L., S.-L.C., L.-W.L., Y.-F.H., T.-C.T., J.-N.L., F.-P.C., S.-A.C.). Originally published1 Oct 2018https://doi.org/10.1161/CIRCULATIONAHA.118.036046Circulation. 2018;138:1485–1487Although oral anticoagulants (OACs) effectively reduce the risk of atrial fibrillation (AF)-associated stroke, the underuse of warfarin is a global issue, especially in Asia.1 The safety and convenience of nonvitamin K antagonist OACs (NOACs) compared with warfarin would probably improve the rates of the appropriate use of OACs for stroke prevention. We aimed to investigate the secular trends of initiation rates of OACs and the risk of ischemic stroke, mortality, and intracranial bleeding among newly diagnosed patients with AF in a nationwide cohort study.From January 1, 2008, to December 31, 2015, 181 214 newly diagnosed patients with AF who had a CHA2DS2-VASc score ≥1 for males and ≥2 for females and survived ≥180 days after AF was diagnosed were identified from the Taiwan National Health Insurance Research Database. The initiation rates of OACs (warfarin or NOACs) from prescription fills in ≤180 days after the date of AF diagnosis were analyzed, the differences during the study period were investigated using the Jonckheere-Terpstra test, and P values for trend were reported. The 1-year risk of ischemic stroke, intracranial bleeding, and mortality of patients with incident AF diagnosed in each year were compared to those diagnosed in 2008 using the Cox regression analysis adjusted for age, sex, hypertension, diabetes mellitus, heart failure, prior stroke/transient ischemic attack, vascular diseases, chronic obstructive pulmonary disease, hyperlipidemia, autoimmune diseases, cancer, abnormal renal function, abnormal liver function, anemia, history of bleeding, and use of antiplatelet agents.The present study was approved by the Institutional Review Board at Taipei Veterans General Hospital, Taipei, Taiwan. Informed consent was waived because of anonymous data.The mean (standard deviation) age of newly diagnosed patients with AF increased from 73.1 (12.1) years in 2008 to 74.3 (12.2) years in 2015. Mean CHA2DS2-VASc scores of patients with incident AF for each year showed a significant increasing trend (from 4.16 in 2008 to 4.31 in 2015; P<0.001).Temporal trends of OAC prescription rates for newly diagnosed patients with AF and the risk of adverse events compared to 2008 are shown in the Figure. OAC initiations increased from 13.6% (2008 Q1) to 35.6% (2015 Q3) during the study period (P<0.001). Warfarin use decreased from 13.6% to 9.6%, whereas NOAC use increased from 0% to 26.0%. In 2015 Q3, 35.6% of patients with incident AF were prescribed OACs for stroke prevention after AF was newly diagnosed (warfarin 9.6%, dabigatran 11.5%, rivaroxaban 11.5%, and apixaban 2.9%). NOACs accounted for ≈73% of overall OACs prescribed for patients with incident AF.Download figureDownload PowerPointFigure. Temporal trends of the initiation rates of OACs and the risk of adverse events. The initiation rates of OACs after AF was newly diagnosed significantly increased from 13.6% to 35.6%, contemporaneous with the introduction of NOACs (from 0.3% to 26.0%). The 1-year risk of ischemic stroke and mortality after AF diagnosis was lower in the era of NOACs compared to year 2008. HR indicates hazard ratio; ICH, intracranial hemorrhage; NOACs, nonvitamin K antagonist oral anticoagulants; OACs, oral anticoagulants; and Q, quarter.Compared with 2008, the risk of ischemic stroke was significantly lower in 2012 (adjusted hazard ratio [HR], 0.814; 95% CI, 0.745–0.888; P<0.001), 2013 (adjusted HR, 0.805; 95% CI, 0.734–0.882; P<0.001), 2014 (adjusted HR, 0.836; 95% CI, 0.762–0.915; P<0.001), and 2015 (adjusted HR, 0.693; 95% CI, 0.611–0.748; P 2-fold increase in the prescription rates of OACs after NOACs became available was observed in the present study. Although the CHA2DS2-VASc score of patients with incident AF were increasingly higher over the period studied, the risk of ischemic stroke was significantly lower between 2012 and 2015. This phenomenon could be at least partly explained by the improved rates of initiations of OACs for patients with incident AF after NOACs were introduced. Despite the increase in the rate of OAC use, the risk of intracranial bleeding did not significantly increase, which again may relate to the safety of NOACs. It is important to note that the adjusted risk of mortality was lower in the era of NOACs despite the age of patients with incident AF at diagnosis becoming older. However, we can only state that by secular trends, the lower risk of mortality may be associated with the increase in NOAC use, but this should not be construed as a causality because this is not a prospective controlled trial and because we cannot exclude the possibility that improvements in patient care other than OACs (eg, better risk factor management) may also contribute to the better survival of patients with AF.5Our study had several limitations. First, information about the types of AF and compliance and adherence of OACs was not available. Also, international normalized ratio data on warfarin were not recorded in the registry database.In conclusion, the initiation rates of OACs in newly diagnosed patients with AF significantly increased from 13.6% to 35.6%, contemporaneous with the introduction of NOACs. A lower risk of ischemic stroke and mortality was temporally associated with the increasing prescription rates of OACs.AcknowledgmentsThis study is based on data provided by the Health and Welfare Data Science Center, Ministry of Health and Welfare, Taiwan. The interpretation and conclusions contained herein do not represent those of the Health and Welfare Data Science Center or Ministry of Health and Welfare.Sources of FundingThis work was supported in part by grants from the Ministry of Science and Technology (MOST 107-2314-B-075-062-MY3) and Taipei Veterans General Hospital (V107B-001, V107B-022, V107C-200), Taipei, Taiwan.DisclosuresNone.Footnotes*Drs Lip and Chen contributed equally as joint senior authors.Data sharing: The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure.https://www.ahajournals.org/journal/circShih-Ann Chen, MD, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd, Taipei, Taiwan 11217 Email [email protected]hinet.netGregory Y. H. 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