Evolution of antithrombotic therapy for patients with atrial fibrillation: The prospective global GLORIA-AF registry program

Abstract

Objective: To assess baseline characteristics and antithrombotic treatment (ATT) prescription patterns in patients enrolled in the third phase of the GLORIA-AF Registry Program, evaluate predictors of treatment prescription, and compare results with phase II.

Methods: GLORIA-AF is a large, global, prospective registry program, enrolling patients with newly diagnosed nonvalvular atrial fibrillation (AF) at risk of stroke. Patients receiving dabigatran were followed for two years in phase II, and all patients were followed for 3 years in phase III. Phase II started when dabigatran became available; phase III started when the characteristics of patients receiving dabigatran became roughly comparable with those receiving vitamin K antagonists (VKAs).

Results: Between 2014 and 2016, 21,241 patients were enrolled in phase III. In total, 82% of patients were prescribed oral anticoagulation ([OAC]; 59.5% novel/nonvitamin K oral anticoagulants [NOACs], 22.7% VKAs). A further 11% of patients were prescribed antiplatelets without OAC and 7% were prescribed no ATT. A high stroke risk was the main driver of OAC prescription. Factors associated with prescription of VKA over NOAC included type of site, region, physician specialty, and impaired kidney function.

Conclusion: Over the past few years, data from phase III of GLORIA-AF show that OACs have become the standard treatment option, with most newly diagnosed AF patients prescribed a NOAC. However, in some regions a remarkable proportion of patients remain undertreated. In comparison with phase II, more patients received NOACs in phase III while the prescription of VKA decreased. VKAs were preferred over NOACs in patients with impaired kidney function.

Fig 1. Factors most strongly associated with prescription of no OAC treatment (AP only and no treatment) versus OAC therapy (NOAC and VKA) in phase II (A) and phase III (B).

AF, atrial fibrillation; BMI, body mass index; CHA₂DS₂−VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke/transient ischemic attack/systemic embolism, vascular disease, age from 65–74 years, sex category [female]); CI, confidence interval; F, female; HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly [>65 years], drugs or alcohol concomitantly); M, male; NOAC, novel/nonvitamin K oral anticoagulants; OAC, oral anticoagulation; ref, reference; RR, relative risk; TIA, transient ischemic attack; VKA, vitamin K antagonist. *Effect estimates obtained from the model including all variables of interest and the risk scores, but not the components of the risk scores.

Fig 2. Factors most strongly associated with prescription of NOAC versus VKA in phase II (A) and phase III (B).

AF, atrial fibrillation; CHA₂DS₂−VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke/transient ischemic attack/systemic embolism, vascular disease, age from 65–74 years, sex category [female]); CI, confidence interval; F, female; GP, general practitioner; HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly [>65 years], drugs or alcohol concomitantly); M, male; NOAC, novel/nonvitamin K oral anticoagulants; PCP, primary care physician; ref, reference; RR, relative risk; TIA, transient ischemic attack; VKA, vitamin K antagonist. *Effect estimates obtained from the model including all variables of interest and the risk scores, but not the components of the risk scores.

Fig 3. Factors most strongly associated with prescription of AP only versus no ATT in phase II (A) and phase III (B).

AP, antiplatelet; ATT, antithrombotic treatment; CHA₂DS₂−VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, stroke/transient ischemic attack/systemic embolism, vascular disease, age from 65–74 years, sex category [female]); CI, confidence interval; F, female; GP, general practitioner; HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly [>65 years], drugs or alcohol concomitantly); M, male; PCP, primary care physician; ref, reference; RR, relative risk. *Effect estimates obtained from the model including all variables of interest and the risk scores, but not the components of the risk scores.

Fig 4. Analysis of ATT pattern in phase III by countries.

AP, antiplatelet; ARG, Argentina; ATT, antithrombotic treatment; AUT, Austria; BEL, Belgium; BGR, Bulgaria; BRA, Brazil; CAN, Canada; CHE, Switzerland; CHL, Chile; CHN, China; COL, Colombia; CZE, Czech Republic; DNK, Denmark; DEU, Germany; ECU, Ecuador; ESP, Spain; EST, Estonia; FRA, France; GBR, United Kingdom of Great Britain and Northern Ireland; GRC, Greece; HKG, Hong Kong; HRV, Croatia; IRL, Ireland; ITA, Italy; JPN, Japan; KOR, Korea; LVA, Latvia; MEX, Mexico; NLD, the Netherlands; NOAC, novel/nonvitamin K oral anticoagulants; NOR, Norway; PER, Peru; POL, Poland; PRT, Portugal; ROU, Romania; RUS, Russian Federation; SGP, Singapore; SVN, Slovenia; TWN, Taiwan; USA, United States of America; VKA, vitamin K antagonist.