Several studies have shown that the prescription of antiplatelet therapy (APT) is associated with an increased risk of oral anticoagulant (OAC) underuse in patients aged 75 years and over with atrial fibrillation (AF). An associated atheromatous disease may be the underlying reason for APT prescription. The objective of the study was to determine whether the association between underuse of OAC and APT prescription was explained by the presence of an atheromatous disease.
Methods and Results
We performed a retrospective, observational, single-centre study between 2009 and 2013 based on administrative data. Patients aged 75 years and over with non-valvular AF were identified in a database of 72,090 hospital stays. Prescriptions of anti-thrombotic medications and their association with the presence of atheromatous disease were evaluated by the mean of a logistic regression. A total of 2034 hospital stays were included (mean age 84.3 ± 5.2 years). The overall prevalence of known atheromatous disease was 25.9%. OAC underuse was observed in 58.5% of the stays. In multivariable analysis, the prescription of an APT was associated with an increased risk of OAC underuse [odds ratio (OR) 6.85; 95% confidence interval (CI) 5.50–8.58], independently of the presence of a concomitant known atheromatous disease (OR 0.78; 95% CI 0.60–1.01). Among the 692 stays with APT monotherapy (34.0%), 232 (33.5%) displayed an atheromatous disease.
The underuse of OAC is associated with the prescription of APT in older patients with AF, regardless of the presence or absence of known atheromatous disease. Our results suggest that APT is often inappropriately prescribed instead of OAC.
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January CT, Wann LS, Alpert JS, Calkins H, Cleveland JC, Cigarroa JE, et al. AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol [Internet]. 2014. doi:10.1016/j.jacc.2014.03.022.
European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GYH, Schotten U, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010;31(19):2369–429.
Camm AJ, Lip GYH, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012;33(21):2719–47.
Friberg L, Rosenqvist M, Lip G. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182,678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J. 2012;33(12):1500–10.
Olesen JB, Lip G, Hansen PR, Lindhardsen J, Ahlehoff O, Andersson C, et al. Bleeding risk in “real world” patients with atrial fibrillation: comparison of two established bleeding prediction schemes in a nationwide cohort. J Thromb Haemost. 2011;9(8):1460–7.
Dalleur O, Wouters D, Spinewine A, Boland B, Maes F, Scavee C, et al. Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation? Clin Interv Aging. 2014;9:1091–9.
Kirchhof P, Ammentorp B, Darius H, Caterina RD, Heuzey J-YL, Schilling RJ, et al. Management of atrial fibrillation in seven European countries after the publication of the 2010 ESC Guidelines on atrial fibrillation: primary results of the PREvention oF thromboemolic events—European Registry in Atrial Fibrillation (PREFER in AF). Europace. 2014;16(1):6–14.
Forslund T, Wettermark B, Wändell P, von Euler M, Hasselström J, Hjemdahl P. Risks for stroke and bleeding with warfarin or aspirin treatment in patients with atrial fibrillation at different CHA(2)DS(2)VASc scores: experience from the Stockholm region. Eur J Clin Pharmacol. 2014;70(12):1477–85.
Marcucci M, Nobili A, Tettamanti M, Iorio A, Pasina L, Djade CD, et al. Joint use of cardio-embolic and bleeding risk scores in elderly patients with atrial fibrillation. Eur J Intern Med. 2013;24(8):800–6.
Piccini JP, Fraulo ES, Ansell JE, Fonarow GC, Gersh BJ, Go AS, et al. Outcomes registry for better informed treatment of atrial fibrillation: rationale and design of ORBIT-AF. Am Heart J. 2011;162(4):606–12 (e1).
Lip G. The role of aspirin for stroke prevention in atrial fibrillation. Nat Rev Cardiol. 2011;8(10):602–6.
Olesen JB, Lip G, Lindhardsen J, Lane DA, Ahlehoff O, Hansen ML, et al. Risks of thromboembolism and bleeding with thromboprophylaxis in patients with atrial fibrillation: a net clinical benefit analysis using a “real world” nationwide cohort study. Thromb Haemost. 2011;106(4):739–49.
Mant J, Hobbs FR, Fletcher K, Roalfe A, Fitzmaurice D, Lip GY, et al. Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet. 2007;370(9586):493–503.
Rash A, Downes T, Portner R, Yeo WW, Morgan N, Channer KS. A randomised controlled trial of warfarin versus aspirin for stroke prevention in octogenarians with atrial fibrillation (WASPO). Age Ageing. 2007;36(2):151–6.
Wolff A, Shantsila E, Lip G, Lane DA. Impact of advanced age on management and prognosis in atrial fibrillation: insights from a population-based study in general practice. Age Ageing. 2015;44(5):874–8.
Organisation European Stroke, Tendera M, Aboyans V, Bartelink M-L, Baumgartner I, Clément D, et al. ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(22):2851–906.
Fifth Joint Task Force of the European Society of Cardiology, European Association of Echocardiography, European Association of Percutaneous Cardiovascular Interventions, European Heart Rhythm Association, Heart Failure Association, European Association for Cardiovascular Prevention & Rehabilitation, et al. European guidelines on cardiovascular disease prevention in clinical practice (version 2012): the Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur J Prev Cardiol. 2012;19(4):585–667.
Steinberg BA, Kim S, Piccini JP, Fonarow GC, Lopes RD, Thomas L, et al. Use and associated risks of concomitant aspirin therapy with oral anticoagulation in patients with atrial fibrillation: insights from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) Registry. Circulation. 2013;128(7):721–8.
Lip GYH, Laroche C, Dan G-A, Santini M, Kalarus Z, Rasmussen LH, et al. “Real-world” antithrombotic treatment in atrial fibrillation: the EORP-AF pilot survey. Am J Med. 2014;127(6):519–29 (e1).
Beuscart R, McNair P, Brender J. PSIP consortium. Patient safety through intelligent procedures in medication: the PSIP project. Stud Health Technol Inform. 2009;148:6–13.
World Health Organization. International Classification of Diseases (ICD) [Internet]. WHO. [cited 2015 Aug 25]. 2015. http://www.who.int/classifications/icd/en/.
World Health Organization. Anatomical Therapeutic Chemical [Internet]. [cited 2015 Aug 25]. 2015. http://www.whocc.no/atc_ddd_index/.
IUPAC-International Union of Pure and Applied Chemistry. [Internet]. [cited 2015 Aug 25]. 2015. http://www.iupac.org/.
Chazard E, Mouret C, Ficheur G, Schaffar A, Beuscart J-B, Beuscart R. Proposal and evaluation of FASDIM, a fast and simple de-identification method for unstructured free-text clinical records. Int J Med Inf. 2014;83(4):303–12.
Li B, Evans D, Faris P, Dean S, Quan H. Risk adjustment performance of Charlson and Elixhauser comorbidities in ICD-9 and ICD-10 administrative databases. BMC Health Serv Res. 2008;8:12.
Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi J-C, et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005;43(11):1130–9.
Sundararajan V, Quan H, Halfon P, Fushimi K, Luthi J-C, Burnand B, et al. Cross-national comparative performance of three versions of the ICD-10 Charlson index. Med Care. 2007;45(12):1210–5.
Lip GYH, Nieuwlaat R, Pisters R, Lane DA, Crijns HJGM. 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(2):263–72.
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ. Validation of clinical classification schemes for predicting stroke: results from the national registry of atrial fibrillation. JAMA. 2001;285(22):2864–70.
Gardner C, Rankin JM, Geelhoed E, Nguyen M, Newman M, Cutlip D, et al. Evaluation of long-term clinical and health service outcomes following coronary artery revascularisation in Western Australia (WACARP): a population-based cohort study protocol. BMJ Open. 2014;4(10):e006337.
Park H-K, Yoon S-J, Ahn H-S, Ahn LS, Seo H-J, Lee S-I, et al. Comparison of risk-adjustment models using administrative or clinical data for outcome prediction in patients after myocardial infarction or coronary bypass surgery in Korea. Int J Clin Pract. 2007;61(7):1086–90.
Margolis J, Barron JJ, Grochulski WD. Health care resources and costs for treating peripheral artery disease in a managed care population: results from analysis of administrative claims data. J Manag Care Pharm JMCP. 2005;11(9):727–34.
Taljaard M, Tuna M, Bennett C, Perez R, Rosella L, Tu JV, et al. Cardiovascular Disease Population Risk Tool (CVDPoRT): predictive algorithm for assessing CVD risk in the community setting. A study protocol. BMJ Open. 2014;4(10):e006701.
McCormick N, Lacaille D, Bhole V, Avina-Zubieta JA. Validity of myocardial infarction diagnoses in administrative databases: a systematic review. PLoS One. 2014;9(3):e92286.
Monesi L, Tettamanti M, Cortesi L, Baviera M, Marzona I, Avanzini F, et al. Elevated risk of death and major cardiovascular events in subjects with newly diagnosed diabetes: findings from an administrative database. Nutr Metab Cardiovasc Dis. 2014;24(3):263–70.
Fan J, Arruda-Olson AM, Leibson CL, Smith C, Liu G, Bailey KR, et al. Billing code algorithms to identify cases of peripheral artery disease from administrative data. J Am Med Inform Assoc JAMIA. 2013;20(e2):e349–54.
van de Steeg-van Gompel CHPA, Wensing M, Braspenning J, De Smet PAGM. The usefulness of antiplatelet prescriptions for the identification of patients with atherothrombosis in primary care: a Dutch cross-sectional study. J Eval Clin Pract. 2012;18(4):866–71.
Chazard E, Băceanu A, Ferret L, Ficheur G. The ADE scorecards: a tool for adverse drug event detection in electronic health records. Stud Health Technol Inform. 2011;166:169–79.
Lip G, Nieuwlaat R, Pisters R, Lane DA, Crijns HJGM. 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 J. 2010;137(2):263–72.
Rothendler JA, Rose AJ, Reisman JI, Berlowitz DR, Kazis LE. Choices in the use of ICD-9 codes to identify stroke risk factors can affect the apparent population-level risk factor prevalence and distribution of CHADS2 scores. Am J Cardiovasc Dis. 2012;2(3):184.
Mercaldi CJ, Ciarametaro M, Hahn B, Chalissery G, Reynolds MW, Sander SD, et al. Cost efficiency of anticoagulation with warfarin to prevent stroke in Medicare beneficiaries with nonvalvular atrial fibrillation. Stroke. 2011;42(1):112–8.
R Core Team. R: a language and environment for statistical computing [Internet]. R Foundation for Statistical Computing. 2014. http://www.R-project.org.
Hanon O, Assayag P, Belmin J, Collet JP, Emeriau JP, Fauchier L, et al. Expert consensus of the French Society of Geriatrics and Gerontology and the French Society of Cardiology on the management of atrial fibrillation in elderly people. Arch Cardiovasc Dis. 2013;106(5):303–23.
Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893–962.
Deitelzweig SB, Jing Y, Swindle JP, Makenbaeva D. Reviewing a clinical decision aid for the selection of anticoagulation treatment in patients with nonvalvular atrial fibrillation: applications in a US managed care health plan database. Clin Ther. 2014;36(11):1566–73 (e3).
Fuchs P, Vogel T, Lang P-O. [Anticoagulation in the aged patient with atrial fibrillation: what are prescribing cardiologists, geriatricians and general practitioners?] Rev Médecine Interne Fondée Par Société Natl Francaise. Médecine Interne. 2015;36(8):509–15.
Shantsila E, Wolff A, Lip G, Lane DA. Optimising stroke prevention in patients with atrial fibrillation: application of the GRASP-AF audit tool in a UK general practice cohort. Br J Gen Pract J R Coll Gen Pract. 2015;65(630):e16–23.
Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, Rich MW, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006;151(3):713–9.
Bahri O, Roca F, Lechani T, Druesne L, Jouanny P, Serot J-M, et al. Underuse of oral anticoagulation for individuals with atrial fibrillation in a nursing home setting in France: comparisons of resident characteristics and physician attitude. J Am Geriatr Soc. 2015;63(1):71–6.
Barnes GD, Gu X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, et al. The predictive ability of the CHADS2 and CHA2DS2-VASc scores for bleeding risk in atrial fibrillation: the MAQI(2) experience. Thromb Res. 2014.
We sincerely thank all the physicians who participated in the PSIP project in their respective departments, notably Dr. Pascale Leurs, Dr. Olivier Brimont, Dr. Zine Baarir, and Dr. Philippe Lecocq. We thank Renaud Perichon and Sophie Quenton (health informatics engineers) for their precious assistance.
Conflict of interest
Lorette Averlant, Grégoire Ficheur, Laurie Ferret, Stéphane Boulé, François Puisieux, Michel Luyckx, Julien Soula, Alexandre Georges, Régis Beuscart, Emmanuel Chazard, and Jean-Baptiste Beuscart declare that they have no conflict of interest that might be relevant to the contents of this article.
This study was funded by the Fondation pour la Recherche Médicale (FRM). Responsibility for the design, analysis, interpretation of data and conclusions lies with the authors.
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Averlant, L., Ficheur, G., Ferret, L. et al. Underuse of Oral Anticoagulants and Inappropriate Prescription of Antiplatelet Therapy in Older Inpatients with Atrial Fibrillation. Drugs Aging 34, 701–710 (2017). https://doi.org/10.1007/s40266-017-0477-3