Outpatient use of anticoagulants, rate-controlling drugs, and antiarrhythmic drugs for atrial fibrillation
ABSTRACT The first clinical practice guidelines for management of atrial fibrillation (AF) were published in 2001. We explored the use of anticoagulants, rate-controlling drugs, and antiarrhythmic drugs in patients with AF during the 4 years surrounding publication of these guidelines.
Mentions of warfarin, beta-blockers, digoxin, diltiazem, verapamil, and all class I and class III antiarrhythmic drugs made by US office-based physicians during patient visits for AF between October 1999 and September 2003 were evaluated using the IMS Health National Disease and Therapeutic Index (Plymouth Meeting, PA). Medication use by patient age, sex, and physician specialty was explored. Trends in use during the study period were estimated.
Warfarin was mentioned in an average of 37% of all AF-related visits across the observation period, with no statistically significant change over time. Digoxin was the most commonly mentioned rate-controlling drug in 23% of patient visits, followed by beta-blockers in 11% and calcium-channel blockers in 8%. Over the study period, mentions of digoxin significantly decreased, and mentions of beta-blockers significantly increased. Mentions of antiarrhythmic drugs were reported in an average of 12% of patient visits, with no significant change over the study period.
Observed trends in use of digoxin, beta-blockers, and class Ia antiarrhythmic drugs were consistent with evidence-based recommendations. However, only approximately one third of patient visits for AF included mentions of warfarin, even among patients aged > or = 60 years. These results indicate the need for continued education and interventions, especially regarding stroke prevention, in patients with AF.
[Show abstract] [Hide abstract]
ABSTRACT: Prescribing rate control medications with or without antiarrhythmic drugs is often the first course treatment for atrial fibrillation (AF). Clinical trial data suggest that antiarrhythmic drugs are only marginally effective and have multiple drawbacks, while rate control alone is sufficient for most patients with minimally symptomatic AF. Objectives This study investigates changes in the use of oral rate and rhythm control therapy for AF during years 2002-2011 in the U.S. Veterans Health Administration (VHA). Methods Patients with new AF episodes were identified in VHA administrative data files and receipt of oral rate and rhythm controlling drugs within 90 days of new AF episodes was determined for each patient. Results The percentage of patients receiving an oral rate controlling medication decreased from 74.9% in 2002-2003 to 70.9% in 2010-2011. The use of digoxin decreased by over 50%, while the use of beta blockers metoprolol and carvedilol increased. The proportion of patients receiving any oral antiarrhythmic medication decreased from 13.5% in 2002-2003 to 11.6% in 2010-2011 and use of the most frequently prescribed oral antiarrhythmic, amiodarone, decreased by 17%. Conclusions Rate control remains the dominant strategy for treating new AF. The decrease in the use of oral antiarrhythmics may be due to lack of concrete data suggesting mortality and morbidity benefit as well as increasing utilization of the ablation approach. Bullet points The proportion of patients with new AF episodes who were prescribed oral rate or rhythm control medications decreased modestly from 2002 through 2011. The use of digoxin decreased by over 50%, and amiodarone decreased by 17%. Rate control remains the dominant strategy for treating new AF.American Heart Journal 07/2014; 168(1). DOI:10.1016/j.ahj.2014.03.024 · 4.56 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: This systematic review aims to provide an update on pharmacology, efficacy and safety of the newer oral direct thrombin and factor Xa inhibitors, which have emerged for the first time in ~60years as cogent alternatives to warfarin for stroke prophylaxis in non-valvular atrial fibrillation. We also discuss on four of the most common clinical scenarios with several unsolved questions and areas of uncertainty that may play a role in physicians' reluctance to prescribe the newer oral anticoagulants such as 1) patients with renal failure; 2) the elderly; 3) patients presenting with atrial fibrillation and acute coronary syndromes and/or undergoing coronary stenting; and 4) patients planning to receive AF ablation with the use of pulmonary vein isolation. New aspects presented in current guidelines are covered and we also propose an evidence-based anticoagulation management algorithm.International journal of cardiology 04/2014; 174(3). DOI:10.1016/j.ijcard.2014.04.179 · 6.18 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Abstract Objective: The management of atrial fibrillation (AF) involves two choices: 1) rate control versus rhythm control, and 2) anticoagulation treatment based upon risk of stroke. The objective of the study was to describe practice patterns in both of these treatment areas in patients with newly diagnosed AF among a commercially-insured population. Methods: This retrospective administrative claims analysis included patients with ≥2 AF claims between 01/01/2008 and 09/30/2010. Patients with AF claims within a year prior to the index date (i.e., the first AF diagnosis) were excluded. The primary outcome was the proportion of patients treated with rate control (i.e., beta blockers, calcium channel blockers, digoxin) versus rhythm control (i.e., electrical cardioversion, left atrial catheter ablation (LACA), and/or surgical ablation) and the use of anticoagulants stratified by risk of stroke based on CHADS2 score.) Results: Of 48,814 patients with a diagnosis of AF, 38,502 (78.9%) received treatment. Of those treated, the majority received only pharmacologic treatment (73.4%), of which beta blockers were predominantly used in the initial regimen (66.7%). Antiarrhythmic drugs were used in 23.9% of patients, but within the initial regimen in only 11.7% of patients. Direct current cardioversion occurred in 18.2% of patients, with majority being either first line (8.5%) or second line (9.1%) therapy. LACA was used in only 5.2% of patients and was typically reserved for use after pharmacologic treatment or direct current cardioversion. Of 1,924 patients who received LACA, 14.6% received a repeat procedure and 53.4% of the repeat procedures occurred within 6 months of the initial one. A little more than half of all patients (57.0%) received anticoagulant therapy (predominantly warfarin); of those at high risk for stroke, 63.8% with a CHADS2 score ≥2 received anticoagulants. Key Limitations: It is a retrospective analysis using administrative claims data from a commercially insured population only. Identification of the first episode of AF may be inaccurate, and we cannot differentiate between paroxysmal and persistent AF. Conclusions: Debate continues regarding whether the preferred management of most patients with AF is through rate control or restoration of normal sinus rhythm. Our retrospective study found that treatments to restore normal heart rhythm, including LACA, which could be considered aggressive initial treatment, were typically reserved as second or third line alternatives. Initial standard of care for the majority patients was beta blockers. Though use of anticoagulation may be higher than other observational studies, opportunities exist to increase treatment in high risk patients.Current Medical Research and Opinion 05/2014; 30(9). DOI:10.1185/03007995.2014.922061 · 2.37 Impact Factor