What are you prescribing for atrial fibrillation?

Dr Aajuli Shukla

writer

Dr Aajuli Shukla

General Practitioner; Deputy Medical Editor, Medical Journal of Australia; Member of the Editorial Advisory Board for the Diabetes Management Journal

Dr Aajuli Shukla

 

Despite the widespread uptake of DOACs, they are still underutilised and atrial fibrillation is still undertreated in Australia.

This is according to Dr Andrew Sindone, Cardiologist and Director of the Heart Failure Unit and Department of Cardiac Rehabilitation at Concord Hospital, New South Wales.

“The general practitioner is the gatekeeper. They are often the ones who detect it [atrial fibrillation], or suspect it, and either treat it or refer on.”

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1 Figure 1 of the paper. https://doi.org/10.1016/j.hlc.2018.03.010

2 “Australians with non-valvular atrial fibrillation are currently using NOACs in preference to warfarin at a ratio of 2:1.”
https://doi.org/10.1016/j.hlc.2018.03.010

3 In this nationwide cohort study of patients ≥75 years initiating oral anticoagulation for AF, standard and reduced dose NOACs were associated with similar risks of stroke/SE as warfarin and lower or similar risks of bleeding. The NOACs seem to be a safe option also in elderly patients. https://heart.bmj.com/content/108/5/345

4 The use of DOACs is a reasonable alternative to vitamin K antagonists in AF patients with CHADS2 score ≥3, advanced age, and HF. The RI constitutes a useful, additional tool to facilitate clinicians in choosing DOACs or warfarin in particular category of AF patients. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6761253/

5 “Warfarin was associated with a greater decline in eGFR than either low-dose (HR: 0.81, 95% CI: 0.69–0.96) or standard-dose dabigatran (HR: 0.79, 95% CI: 0.68–0.93), whereas apixaban showed a similar risk of acute renal failure compared with warfarin in ARISTOTLE trial (RR: 0.97, 95% CI: 0.88–1.07)” https://journals.lww.com/md-journal/Fulltext/2019/11290/The_impact_of_renal_function_on_efficacy_and.87.aspx

6 However, mechanical heart valves currently pose an absolute contraindication to NOACs based on the results of a single phase II study comparing dabigatran and warfarin (RE-ALIGN [Randomized, Phase II Study to Evaluate the Safety and Pharmacokinetics of Oral Dabigatran Etexilate in Patients after Heart Valve Replacement]). That trial was stopped prematurely because of an excess of both stroke and bleeding with the dabigatran doses tested https://doi.org/10.1161/CIRCULATIONAHA.118.035612

7 Individual state government sites and also this article from RACGP https://www.racgp.org.au/afp/2014/may/anticoagulation

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Dr Aajuli Shukla

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Dr Aajuli Shukla

General Practitioner; Deputy Medical Editor, Medical Journal of Australia; Member of the Editorial Advisory Board for the Diabetes Management Journal

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