Minority Patients with AFib Less Likely to Receive Oral Anticoagulation than White Counterparts

Utibe Essien, MD, MPH

Black patients with atrial fibrillation (AF) are 25% less likely to receive a prescription for oral anticoagulation than their non-Hispanic White counterparts and 27% less likely to be discharged with a prescription for a direct oral anticoagulant (DOAC), according to a new analysis.

An analysis of data from the Get With The Guidelines-Atrial Fibrillation (GWTG-AFIB) Registry, results provide insight into associations of race and ethnicity with oral anticoagulation therapy in people with AF as well as the risk of adverse outcomes, including stroke and mortality.

“In a national registry of patients hospitalized with AF, Black and Hispanic patients compared with White patients were less likely to be prescribed anticoagulation at hospital discharge, particularly DOACs,” investigators wrote. “These differences persisted despite substantial improvements in overall OAC prescribing over time. Black patients also had higher rates of AF-related adverse outcomes, including stroke (also higher in Hispanic patients), bleeding, and mortality.”

Led by Utibe Essien, MD, MPH, of the University of Pittsburgh School of Medicine, the current study was launched with the intent of using the American Heart Association’s GWTG-AFIB Registry to develop a greater understanding of contemporary hurdles to optimized management of AF in the US. With this in mind, investigators designed the study to assess whether race and ethnicity were associated with oral anticoagulant use and long-term outcomes in patients with AF in analyses adjusted for socioeconomic status and community-level social determinants of health.

A national quality improvement initiative launched in 2013, the GWTG-AFIB Registry collects data from hospitals across the US related to demographic, medical history, and clinical characteristics of people with AF. Using data collected from 2014-2020, investigator designed their study as a retrospective cohort analysis with prescription of a DOAC or warfarin at discharge serving as the primary outcome of interest. Secondary outcomes of interest included cumulative 1-year incidence of ischemic stroke, major bleeding, and mortality postdischarge. Investigators pointed out analyses assessing primary and secondary outcomes were adjusted for patient demographic, clinical, and socioeconomic characteristics.

From the 159 participating sites, investigators obtained data related to 69,553 people hospitalized with AF from 2014-2020. This cohort had a median age of 72 (IQR, 63-80) years, a median CHA2DS2-VASc score of 4 (IQR, 2-5), and 49.1% were women. Among the study cohort, 85.6% (n=59,570) were non-Hispanic White, 5.8% (n=4058) were Hispanic, 7.3% (n=5062) were Black, and 1.2% (n=863) were Asian. Overall, 81.1% of people were prescribed oral anticoagulation therapy at discharge, with 74.1% receiving a DOAC.

Initial analysis indicated oral anticoagulation prescription was lowest among Hispanic patients (3010 [74.2%]), followed by Black patients (3935 [77.7%]), Asian patients (691 [80.1%]), and White patients (48 749 [81.8%]). In adjusted analyses, Black patients with AF were less likely than White patients to be discharged while taking any anticoagulant (aOR, 0.75 [95% CI, 0.68-0.84]) and DOACs (aOR, 0.73 [95% CI, 0.65-0.82]).

In subgroup analyses restricted to 16,307 individuals with at least 1 year of follow-up data, results suggested Black patients were at an increased risk of bleeding (aHR, 2.08 [95% CI, 1.53-2.83]), stroke (aHR, 2.07 [95% CI, 1.34-3.20]), and mortality (aHR, 1.22 [95% CI, 1.02-1.47]) than their White counterparts. Investigators also pointed out an increased risk of stroke was observed for Hispanic patients compared to White patients (aHR, 2.02 [95% CI, 1.38-2.95]).

“Further qualitative research examining how clinicians assess stroke and bleeding risk among patients with AF from different racial and ethnic groups may help provide clarity to this study finding,” investigators added. “Additionally, the finding that higher rates of bleeding were present in Black patients regardless of anticoagulation status represents an important opportunity for future research examining the safety of DOACs in underrepresented racial and ethnic groups.”

This study, “Association of Race and Ethnicity With Oral Anticoagulation and Associated Outcomes in Patients With Atrial Fibrillation,” was published in JAMA Cardiology.