Observational Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Nov 26, 2022; 14(11): 576-598
Published online Nov 26, 2022. doi: 10.4330/wjc.v14.i11.576
Time trends in antithrombotic therapy prescription patterns: Real-world monocentric study in hospitalized patients with atrial fibrillation
Maurizio Giuseppe Abrignani, Alberto Lombardo, Annabella Braschi, Nicolò Renda, Vincenzo Abrignani, Renzo M Lombardo
Maurizio Giuseppe Abrignani, Alberto Lombardo, Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, ASP Trapani, Trapani 91100, Trapani, Italy
Annabella Braschi, Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo 90100, Palermo, Italy
Nicolò Renda, Department of Medicine and Surgery, University of Parma, Parma 43100, Parma, Italy
Vincenzo Abrignani, Operative Unit of Internal Medicine with Stroke Care, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE) "G. D'Alessandro", University of Palermo, Palermo 90100, Palermo, Italy
Renzo M Lombardo, Department of Cardiology, Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, Trapani 91100, Trapani, Italy
Author contributions: Abrignani MG was responsible for the conception and design of the study, and wrote the first draft of the manuscript; Lombardo A, Braschi A, Renda N, Abrignani V, and Lombardo RM contributed to the design of the study and made critical revisions of the manuscript related to its important intellectual content; and all authors gave final approval of the version of the article to be published.
Institutional review board statement: As this study was a retrospective review of a database with fully anonymized data and without risk of patients’ identification, it does not require ethical approval in our Institution. Permission to use patient data from this facility has been obtained from the Head of Cardiology Unit, S. Antonio Abate Hospital of Trapani.
Informed consent statement: Patients were not required to give informed consent for the study as the analysis used anonymous clinical data that were obtained from a database.
Conflict-of-interest statement: All authors have no disclosures or conflicts of interest.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Maurizio Giuseppe Abrignani, MD, Doctor, Operative Unit of Cardiology, Department of Medicine, S. Antonio Abate Hospital of Trapani, ASP Trapani, Via Mazzini 1, Trapani 91100, Trapani, Italy. maur.abri@alice.it
Received: March 13, 2022
Peer-review started: March 13, 2022
First decision: June 8, 2022
Revised: July 4, 2022
Accepted: October 27, 2022
Article in press: October 27, 2022
Published online: November 26, 2022
Processing time: 255 Days and 10.4 Hours
Abstract
BACKGROUND

Since 2010, the European Society of Cardiology has extended prescription criteria for oral antithrombotic therapy (OAT) in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) were upgraded from an IIAa recommendation in 2012 to an IA in 2016. In real-world scenarios, however, OAC prescription is still suboptimal, mainly for DOACs.

AIM

To evaluate OAT temporal prescription patterns in a cohort of patients hospitalized with AF in a Cardiology Department.

METHODS

A retrospective observational study was conducted on a cohort of hospitalized patients in a secondary setting (Trapani, Italy) from 2010 to 2021 with AF as the main or secondary diagnosis. For 4089 consecutive patients, the variables extracted from the Cardiology department database were: Sex, age, time of hospitalization, antithrombotic therapy (warfarin, acenocoumarol, apixaban, dabigatran, edoxaban, rivaroxaban, aspirin, clopidogrel, other antiplatelet agents, low molecular weight heparin, and fondaparinux), diagnosis at discharge and used resources. Basal features are presented as percentage values for categorized variables and as mean +/- SD for categorized once.

RESULTS

From January 1st, 2010 to October 6th, 2021, 25132 patients were hospitalized in our department; 4089 (16.27%, mean age 75.59+/-10.82) were discharged with AF diagnosis; of them, 2245 were males (54.81%, mean age 73.56+/-11.45) and 1851 females (45.19%, mean age 78.06+/-9.47). Average length of stay was 5.76+/-4.88 days; 154 patients died and 88 were moved to other Departments/Structures. AF was the main diagnosis in 899 patients (21.94%). The most frequent main diagnosis in patients with AF was acute myocardial infarction (1973 discharges, 48.19%). The most frequent secondary cardiac diagnosis was chronic coronary syndrome (1864 discharges, 45.51%), and the most frequent secondary associated condition was arterial hypertension (1010 discharges, 24.66%). For the analysis of antithrombotic treatments, the final sample included 3067 patients, after excluding in-hospital deaths, transferred out or self-discharged patients, as well as discharges lacking indications for prescribed treatments. OAC treatment increased significantly (35.63% in 2010-2012 vs 61.18% in 2019-2021, +25.55%, P < 0.0001), in spite of any antiplatelet agent use. This rise was due to increasing use of DOACs, with or without antiplatelet agents, from 3.04% in 2013-2015 to 50.06% in 2019-2021 (+47.02%, P < 0.0001) and was greater for factor Xa inhibitors, especially apixaban. In addition, treatment with a vitamin K antagonist, in spite of any antiplatelet agent use, decreased from 35.63% in 2010-2012 to 11.12% in 2019-2021 (-24.48%, P < 0.0001), as well as any antiplatelet therapy, alone or in double combination, (49.18% in 2010-2012 vs 34.18% in 2019-2021, -15.00%, P < 0.0001); and patients not receiving antithrombotic therapy declined with time (14.58% in 2010-2012 vs 1.97% in 2021, P < 0.0001).

CONCLUSION

Real-world patients with AF are elderly and affected by cardiovascular and non-cardiovascular diseases. The percentage of patients on OAT and DOACs increased. These data suggest a slow, gradual guidelines implementation process.

Keywords: Atrial fibrillation; Antithrombotic agents; Time series; Warfarin; Direct-acting oral anticoagulants; Aspirin

Core Tip: In this study, the proportion of patients on oral antithrombotic therapy, with or without an antiplatelet agent, increased significantly from 2010 to 2021. This rise was due to increasing use of direct oral anticoagulants, with or without antiplatelet agents. At the same time, there was a gradual decline in the use of vitamin K antagonists, with or without antiplatelet drugs, and of antiplatelet therapy, alone or in double combination, while the proportion of patients not receiving antithrombotic therapy decreased. These data suggest a slow and gradual guidelines implementation process.