Published online Nov 26, 2022. doi: 10.4330/wjc.v14.i11.576
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
International guidelines extended prescription criteria for oral antithrombotic therapy, in particular for direct oral anticoagulants (DOACs) in atrial fibrillation (AF). However, oral anticoagulant (OAC) prescription is still suboptimal, mainly for DOACs.
Considering the huge clinical impact and healthcare economic burden (in terms of both direct medical costs and indirect productivity losses), there are a number of reasons why it is important to complement experimental data with real-life or observational data, investigating OAC treatment in the real world, and the potential nonadherence to AF treatment guidelines. It is, in fact, important that AF guidelines are followed, as non-adherence to OACs is associated with increased ischemic stroke and mortality in high-risk patients.
We aimed to evaluate temporal prescription patterns of antithrombotic agents in a cohort of patients hospitalized with AF in a Cardiology Department. This should be useful in determining how AF guidelines are followed in the real-world.
This was a retrospective, single-center, observational study conducted in the Cardiology Unit of S. Antonio Abate Hospital of Trapani (Western Sicily, Italy). We reviewed the database of medical records of all patients aged ≥ 18 years who were consecutively discharged from January 2010 to 2021. We collected data on demographic and clinical characteristics, including age and sex, main and secondary diagnosis at discharge, diagnostic and therapeutic procedures, and prescribed antithrombotic treatments from the discharge medication list.
From 2010 to 2021, we showed a significant increase in the proportion of AF patients on OAC therapy, regardless of antiplatelet agent use. The main reason for this increase was due to greater DOACs use, mainly FXa inhibitors. Contextually, VKA use, as well as antiplatelet therapy, alone or in double combination, declined; however, the proportion of patients not receiving any antithrombotic therapy globally decreased.
These findings, in line with findings from other European and global datasets, appear consistent with recent changes in AF management guidelines; this suggests, in Italy, an improvement in adherence to guidelines clinical recommendations. Despite this, we should highlight, however, that OAC prescription remains suboptimal over time; thus, a significant proportion of patients with AF still do not receive appropriate treatments for stroke prevention, suggesting that the increasing use of DOACs is not yet closing the gap between scientific evidence, recommendations from academic guidelines and clinical practice in the general population.
Improving the adherence to AF guideline recommendations for stroke prevention with OAC therapy requires further efforts. Clinicians and policy health makers need to develop more specific educational intervention programs for physicians to ensure that OACs, especially DOACs, are appropriately prescribed to eligible patients, in particular to vulnerable subgroups, in order to optimize health resources. We need further studies investigating why OAC treatment in AF patients remains suboptimal, intervening on the relative barriers.