Advertisement

Determinants of Antithrombotic Treatment for Atrial Fibrillation in Octogenarians: Results of the OCTOFA Study

  • Jacques BlacherEmail author
  • Emmanuel Sorbets
  • Dominique Guedj Meynier
  • Jean-Pierre Huberman
  • Jacques Gauthier
  • Serge Cohen
  • Olivier Hoffman
Original Research Article

Abstract

Background and Objective

Atrial fibrillation, the most frequent form of arrhythmia, affects 5–15% individuals aged > 80 years. Stroke is a major risk for atrial fibrillation patients. The benefits of anticoagulant therapy clearly outweigh the risk of hemorrhage, even in the elderly. Despite the efficacy of warfarin, many eligible patients receive no prophylactic antithrombotic therapy. New generation oral anticoagulants compare favorably with vitamin K antagonists in the prevention of thromboembolic events and hemorrhage. These new agents are likely to influence the prescribing habits of anticoagulants in atrial fibrillation. The aim of this study to investigate both the frequency and the determining factors of anticoagulant prescriptions in AF patients aged ≥ 80 years and followed up by private-practice cardiologists in France.

Methods

The OCTOFA (Atrial Fibrillation in Octogenarians) Study assessed the anticoagulant prescribing habits of cardiologists in France. The volunteer cardiologists recruited all consecutive patients fulilling the inclusion criteria.

Results

Between June 2013 and September 2016, 89 cardiologists recruited 738 eligible patients: age ≥ 80 years, non-valvular atrial fibrillation, no other compelling indication for anticoagulation therapy, no recent acute coronary syndrome or stroke. Most (90.7%) patients were on oral anticoagulant therapy: vitamin K antagonist or non-vitamin K antagonist oral anticoagulants, low molecular weight heparin (1.4%), aspirin (5.7%), and no antithrombotic treatment (2.2%). Patients on vitamin K antagonists were older (p < 0.001), had lower renal function (p = 0.033), and had a more frequent history of myocardial infarction (p < 0.001), heart failure (p = 0.001), peripheral artery disease (p = 0.033), major hemorrhage (p = 0.025), and falls (p = 0.045). Four determining factors of anticoagulant prescriptions were statistically significant: high CHA2DS2-VASc score (p < 0.001), high HAS-BLED score (p < 0.001), age > 90 years (p = 0.001), and moderate/severe cognitive impairment (p = 0.002).

Conclusions

Most private-practice cardiologists prescribe anticoagulant treatment according to current guidelines in elderly atrial fibrillation patients. Non-vitamin K antagonist oral anticoagulants represent a significant proportion of prescriptions.

Notes

Acknowledgements

The authors would like to thank the private-practice cardiologists and the patients who agreed to take part in the OCTOFA study. Special thanks go to Fabrice Sberro (Altimed) and Jean-Charles Kerihuel (Vertical) for technical assistance. The authors are also indebted to Moyra Barbier for editorial assistance.

Compliance with Ethical Standards

Conflict of interest

All authors have no conflict of interest to declare.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The CNCF (Collège National des Cardiologues Français) supported all expenses of the OCTOFA study.

Ethical approval

Both the program and the study received approval from the appropriate ethics and administrative committees.

Informed consent

All participants provided written informed consent.

References

  1. 1.
    Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P; ESC Scientific Document Group. ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;2016(37):2893–962.Google Scholar
  2. 2.
    Chugh SS, Havmoeller R, Narayanan K, Singh D, Rienstra M, Benjamin EJ, Gillum RF, Kim YH, McAnulty JH Jr, Zheng ZJ, Forouzanfar MH, Naghavi M, Mensah GA, Ezzati M, Murray CJ. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014;129:837–47.CrossRefGoogle Scholar
  3. 3.
    Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983–8.CrossRefGoogle Scholar
  4. 4.
    Stewart S, Hart CL, Hole DJ, McMurray JJ. A population-based study of the longterm risks associated with atrial fibrillation: 20-year follow-up of the Renfrew/ Paisley study. Am J Med. 2002;113:359–64.CrossRefGoogle Scholar
  5. 5.
    Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137:263–72.CrossRefGoogle Scholar
  6. 6.
    Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel userfriendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138:1093–100.CrossRefGoogle Scholar
  7. 7.
    Graham DJ, Reichman ME, Wernecke M, Zhang R, Southworth MR, Levenson M, Sheu TC, Mott K, Goulding MR, Houstoun M, MaCurdy TE, Worrall C, Kelman JA. Cardiovascular, bleeding, and mortality risks in elderly Medicare patients treated with dabigatran or warfarin for nonvalvular atrial fibrillation. Circulation. 2015;131:157–64.CrossRefGoogle Scholar
  8. 8.
    Lip GY, Laroche C, Ioachim PM, Rasmussen LH, Vitali-Serdoz L, Petrescu L, Darabantiu D, Crijns HJ, Kirchhof P, Vardas P, Tavazzi L, Maggioni AP, Boriani G. Prognosis and treatment of atrial fibrillation patients by European cardiologists: one year follow-up of the EURObservational Research Programme-Atrial Fibrillation General Registry Pilot Phase (EORP-AF Pilot registry). Eur Heart J. 2014;35:3365–76.CrossRefGoogle Scholar
  9. 9.
    Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, Lewis BS, Parkhomenko A, Yamashita T, Antman EM. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383:955–62.CrossRefGoogle Scholar
  10. 10.
    Marinigh R, Lip GY, Fiotti N, Giansante C, Lane DA. Age as a risk factor for stroke in atrial fibrillation patients: implications for thromboprophylaxis. J Am Coll Cardiol. 2010;56:827–37.CrossRefGoogle Scholar
  11. 11.
    Gage BF, Boechler M, Doggette AL, Fortune G, Flaker GC, Rich MW, Radford MJ. Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation. Stroke. 2000;31:822–7.CrossRefGoogle Scholar
  12. 12.
    Cohen N, Almoznino-Sarafian D, Alon I, Gorelik O, Koopfer M, Chachashvily S, Shteinshnaider M, Litvinjuk V, Modai D. Warfarin for stroke prevention still underused in atrial fibrillation: patterns of omission. Stroke. 2000;31:1217–22.CrossRefGoogle Scholar
  13. 13.
    Man-Son-Hing M, Laupacis A. Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians’ fears often unfounded. Arch Intern Med. 2003;163:1580–6.CrossRefGoogle Scholar
  14. 14.
    Jacobs LG, Billett HH, Freeman K, Dinglas C, Jumaquio L. Anticoagulation for stroke prevention in elderly patients with atrial fibrillation, including those with falls and/or early-stage dementia: a single-center, retrospective, observational study. Am J Geriatr Pharmacother. 2009;7:159–66.CrossRefGoogle Scholar
  15. 15.
    Formiga F, Fort I, Reig L, Robles MJ, Espinosa MC, Rodriguez D. Atrial fibrillation in elderly patients with dementia. Gerontology. 2009;55:202–4.CrossRefGoogle Scholar
  16. 16.
    Olesen JB, Sorensen R, Hansen ML, Lamberts M, Weeke P, Mikkelsen AP, Køber L, Gislason GH, Torp-Pedersen C, Fosbøl EL. Non-vitamin K antagonist oral anticoagulation agents in anticoagulant naive atrial fibrillation patients: Danish nationwide descriptive data 2011–2013. Europace. 2015;17:187–93.CrossRefGoogle Scholar
  17. 17.
    Feeney JM, Santone E, DiFiori M, Kis L, Jayaraman V, Montgomery SC. Compared to warfarin, direct oral anticoagulants are associated with lower mortality in patients with blunt traumatic intracranial hemorrhage: a TQIP study. J Trauma Acute Care Surg. 2016;81(5):843–8.CrossRefGoogle Scholar
  18. 18.
    Connolly S, Pogue J, Hart R, Pfeffer M, Hohnloser S, Chrolavicius S, Pfeffer M, Hohnloser S, Yusuf S, ACTIVE Writing Group of the ACTIVE Investigators. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006;367:1903–12.CrossRefGoogle Scholar
  19. 19.
    Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, Lewis BS, Parkhomenko A, Yamashita T, Antman EM. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet. 2014;383:955–62.CrossRefGoogle Scholar
  20. 20.
    Richiardi L, Pizzi C, Pearce N. Representativeness. Int J Epidemiol. 2014;43:632–3.CrossRefGoogle Scholar
  21. 21.
    Fourrier-Réglat A, Droz-Perroteau C, Bénichou J, Depont F, Amouretti M, Bégaud B, Moride Y, Blin P, CADEUS Team. Moore N (2008) Impact of prescriber nonresponse on patient representativeness. Epidemiology. 2008;19:186–90.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Jacques Blacher
    • 1
    Email author
  • Emmanuel Sorbets
    • 2
  • Dominique Guedj Meynier
    • 3
  • Jean-Pierre Huberman
    • 3
  • Jacques Gauthier
    • 3
  • Serge Cohen
    • 3
  • Olivier Hoffman
    • 3
  1. 1.Assistance Publique-Hôpitaux de Paris, Unité HTA, Prévention et Thérapeutique Cardiovasculaires, Centre de Diagnostic et de Thérapeutique, Hôtel-Dieu University HospitalUniversité Paris DescartesParisFrance
  2. 2.AP-HP, Cardiology Department, Avicenne University HospitalParis 13 UniversityBobignyFrance
  3. 3.Collège National des Cardiologues Français (CNCF)ParisFrance

Personalised recommendations