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

Abstract

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 Among OAC users, vitamin K antagonists (VKAs) have been replaced by non-VKA OACs (NOACs) as the more prevalent OAC option in all regions, with highest use in North America (66.5%) and lowest in Asia (50.2%).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.

Impact of direct oral anticoagulant off‐label doses on clinical outcomes of atrial fibrillation patients: A systematic review

“…Similarly, data from the GLORIA‐AF registry showed that AF guideline adherence requires improvement, as nearly half of low‐risk patients are overtreated, and that patients at high risk of stroke were undertreated with oral anticoagulants . Studies from Larock et al McDonald et al and Chowdry et al also reported high values of potentially inappropriate dabigatran prescriptions (31.2–51.1%), which corroborates the problem of off‐label doses with dabigatran.…”

“…In the setting of moderate, mild or no renal impairment, off-label use of the 75 mg dose might result in underdosed patients and may explain why no differences were observed in risk of ischaemic stroke, major gastrointestinal bleeding or mortality between warfarin and the lower dose of dabigatran. This was also seen in a retrospective study conducted in Japan,37 where 54 patients from 228 (23.7%) presented inappropriate dabigatran prescriptions.Similarly, data from the GLORIA-AF registry showed that AF guideline adherence requires improvement, as nearly half of low-risk patients are overtreated, and that patients at high risk of stroke were undertreated with oral anticoagulants 65. Studies from Larock et al 66 McDonald et al 67 and Chowdry et al 68 also reported high values of potentially inappropriate dabigatran prescriptions (31.2-51.1%), which corroborates the problem of off-label doses with dabigatran.…”

Gender Differences in Antithrombotic Treatment for Newly Diagnosed Atrial Fibrillation: The GLORIA-AF Registry Program

“…In addition, a model estimating the effect of gender when adjusting for all other factors has been reported; 34 the effect of gender on anticoagulation was not affected by the adjustments (relative risk of anticoagulant prescription for females compared with males: 0.99 unadjusted vs. 0.99 adjusted for all other factors). We have therefore no reason to suspect that our results were sensitive to this choice.…”

Risk assessment and management of atrial fibrillation patients with left atrial thrombus

“…Similarly, the efficacy of NOACs has been also reported, but the evidence for the NOACs remains relatively scarce due to the relatively small number of studies. This is important to give the increasing widespread use of NOACs in clinical practice, in most regions of the world …”