Regional Differences in Antithrombotic Treatment for Atrial Fibrillation:Insights from the GLORIA-AF Phase II Registry

Introduction Although guideline-adherent antithrombotic therapy (ATT) for stroke prevention in atrial fibrillation (AF) is associated with lower mortality and thromboembolism, ATT uptake shows geographic variation worldwide. We aimed to assess thromboembolic risk and baseline ATT by geographic region and identify factors associated with prescription of ATT in a large, truly global registry of patients with recently diagnosed AF. Methods and Results Our analysis comprises 15,092 patients newly diagnosed with non-valvular AF at risk for stroke, enrolled in Phase II of Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF). Global oral anticoagulation (OAC) use was 79.9%, being highest in Europe (90.1%), followed by Africa/Middle East (87.4%) and Latin America (85.3%), North America (78.3%) and Asia (55.2%). Among OAC users, vitamin K antagonists (VKAs) have been replaced by non-VKA OACs (NOACs) as the more prevalent OAC option in all regions, with highest use in North America (66.5%) and lowest in Asia (50.2%). In Asia, OAC was 80.4% in community hospitals but only 49.8% in university hospitals and 42.6% in specialist offices, and varied from 21.0% in China to 89.7% in Japan (NOACs at 5.8% in China and 83.3% in Japan). Globally, 76.5% of low-risk patients were prescribed ATT (46.1% OAC), whereas 17.7% high-risk patients were not anticoagulated (Europe 8.8%; North America 18.9%; Asia 42.4%). Conclusion Substantial inter- and intra-regional differences in ATT for stroke prevention in AF are evident in this global registry. While guideline-adherent ATT can be further improved, NOACs are the main contributor to high OAC use worldwide.</jats:p

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase&nbsp;1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation&nbsp;disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age&nbsp; 6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score&nbsp; 652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc&nbsp;= 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N&nbsp;= 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in&nbsp;Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in&nbsp;Asia&nbsp;and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

Systematic review of treatment gaps in oral anticoagulant use in atrial fibrillation

Aims: Guidelines endorse long-term oral anticoagulation (OAC) for stroke prophylaxis in patients with atrial fibrillation (AF) and additional stroke risk factors. However, diverse estimates of guideline based OAC treatment are reported. The objective was to provide insight into the variability seen in estimates of OAC treatment uptake and treatment gaps in clinical practice. Methods and results: A systematic review was conducted following Cochrane methodology, using comprehensive search terms for AF and anticoagulation. MEDLINE and EMBASE databases (January 2006–2016) were searched, and prospective and retrospective observational studies reporting OAC use included. Study data and patient characteristics were extracted, OAC rates pooled by study factors, and meta-regression analysis conducted to identify factors associated with OAC uptake.Of 8861 records screened, 155 eligible datasets from 147 studies were identified [median (25th, 75th percentiles) 2259 (595, 10,240) patients, mean age 73.8 ± 7.1 years]. The majority of studies included AF patients with CHA2DS2-VASc >1 [median proportion (25th, 75th percentile) 0.92 (0.83, 1.00)]. OAC use varied across studies [median proportion (25th, 75th percentile) 51.2% (36.7%, 64.7%)] with high heterogeneity (I2 = 100.0%). In the meta-regression analysis [coefficient, p], prospective study design (0.093, p = 0.008), general practitioner treating physician (0.105, p = 0.001) and data collection after 2013 (0.072, p = 0.070) were associated with higher OAC use. Consecutive enrollment (−0.075, p = 0.008) and Asian region (−0.181, p < 0.001) were associated with lower OAC use. Conclusion: Study factors, geographical and treatment settings are associated with estimates of OAC use and are important considerations for researchers and policy makers to appropriately interpret reported anticoagulation treatment rates. Consideration of these factors may help to more effectively measure interventions, and design studies to improve anticoagulation uptake

Stroke Prevention in Atrial Fibrillation. Findings from the GLORIA-AF Registry

Background: The Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF)is a multinational, prospective, 3-phase study to establish the safety and efficacy of dabigatran in patients with newly diagnosednonvalvular atrial fibrillation at risk of stroke. Phase II began when dabigatran, the first non-vitamin K antagonist oral anticoagulant(NOAC) became available.Objectives: The aim of this registry was to describe Phase II baseline clinical data in the general population and the 2-year follow-upof patients treated with dabigatran.Methods: Among 15,644 patients enrolled in the study, 15,308 were eligible and 4,873 received dabigatran. Atrial fibrillation characteristics,follow-up findings and concomitant diseases were recorded and analyzed using descriptive statistics.Results: Forty-five percent of eligible patients were women and median age was 71.0 years (interquartile range: 64-78 years). Patientswere from Europe (47.9%), North America (22.2%), Asia (20.1%), Latin America (6.0%), and the Middle East/Africa (3.9%).Most of them had high risk for stroke (CHA2DS2-VASc score ≥2; 86.1%) and 13.9% had moderate risk (CHA2DS2-VASc score=1). In80.3% of cases, patients received oral anticoagulants: 47.9% NOACs and 32.4% vitamin K antagonists (VKAs); 12.0% received antiplateletagents and 7.6% did not receive antithrombotic treatment. At the 2-year follow-up, 70.5% remained on dabigatran.Conclusions: Data from the GLORIA-AF Phase II registry showed that in nonvalvular AF, NOACs have been highly adopted in clinicalpractice, becoming more frequently prescribed than VKAs. Worldwide, however, a large proportion of patients have remainedundertreated.Introducción: GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) es un registro internacional, prospectivo, en 3 fases, para determinar la seguridad y eficacia de dabigatran en pacientes con fibrilación auricular no valvular recientemente diagnosticada en riesgo de stroke.  La Fase 2 empezó cuando el dabigatran, el primer anticoagulante oral no vitamina K antagonista (NOAC) estuvo disponible. Objetivos: Describir los datos clínicos basales de la fase 2 en la población general y el seguimiento a 2 años de aquellos que recibieron dabigatran. Material y Métodos: Se incluyeron un total de 15644 pacientes de los cuales 15308 fueron elegibles y 4873 recibieron dabigatran. Se analizaron las características de la Fibrilación auricular, hallazgos en el seguimiento y las enfermedades concomitantes. Los datos fueron analizados usando estadísticas descriptivas. Resultados: Del total de pacientes elegibles, 45.5% eran mujeres, con una edad promedio de 71.0 (rango intercuartilo: 64, 78) años. Los pacientes eran de Europa (47.9%), América del Norte (22.2%), Asia (20.1%),  América Latina (6.0%), y Medio Oriente/África (3.9%). La mayoría se encontraba en alto riesgo de stroke (CHA2DS2-VASc score > 2; 86.1%); 13.9% tuvieron riesgo moderado (CHA2DS2-VASc > 1). En general, 80.3% recibieron anticoagulantes orales, de ellos 47.9% recibieron NOACs  y  32.4% antagonistas de la vitamina K (VKA); 12.0% recibieron agentes antiagregantes plaquetarios y 7.6% no recibieron tratamiento antitrombotico. A 2 años de seguimiento, el 70.5% permanecieron en dabigatran. Conclusiones: Los datos de la fase 2 del GLORIA-AF demostraron que en FA no valvular, los NOAC han sido ampliamente adoptados en la práctica clínica, y fueron más frecuentemente prescriptos que los VKA.No obstante una gran proporción de pacientes en todo el mundo permanecieron sin tratamient

Stroke prevention in atrial fibrillation changes after dabigatran availability in China: The GLORIA-AF registry.

BackgroundUntil the approval of dabigatran etexilate, treatment choices for stroke prevention in patients with atrial fibrillation (AF) were vitamin K antagonists (VKAs) or antiplatelet drugs. This analysis explored whether availability of non-vitamin K antagonist oral anticoagulants post-dabigatran approval was associated with changing treatment patterns in China.MethodsGlobal Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation (GLORIA-AF) collected data on antithrombotic therapy choices for patients with newly diagnosed nonvalvular AF at risk for stroke. In China, enrollment in phase 1 (before dabigatran approval) and phase 2 (after dabigatran approval) occurred from 2011 to 2013 and 2013 to 2014, respectively. Analyses were restricted to sites within China that contributed patients to both phases. The weighted average of the site-specific results was estimated for standardization. Sensitivity analyses used multiple regression.ResultsThirteen sites participated in both phase 1 (419 patients) and phase 2 (276 patients), 76.1% and 16.0% were known to be at high risk for stroke (CHA2DS2-VASc ≥2) and bleeding (HAS-BLED ≥3); 55.5% were male. In phase 1, 16.7%, 61.6%, and 21.7% of patients were prescribed oral anticoagulants (OACs), antiplatelet agents, and no treatment, respectively. Respective proportions were 26.4%, 40.6%, and 33.0% in phase 2. The absolute increase in the site-standardized proportion of patients prescribed OACs after dabigatran availability was 9.9% (95% confidence interval [CI]: 3.7%-16.0%). There was a standardized 17.3% (95% CI: -24.3% to -10.4%) absolute decrease in antiplatelet agent use.ConclusionsThere was an increase in OAC and decrease in antiplatelet agent prescription since dabigatran availability in China. However, a large proportion of AF patients at risk for stroke remained untreated