Influence of Direct Oral Anticoagulants on Rates of Oral Anticoagulation for Atrial Fibrillation

Lucas N. Marzec, Jingyan Wang, Nilay D. Shah, Paul S. Chan, Henry H. Ting, Kensey L. Gosch, Jonathan C. Hsu, Thomas M. Maddox

Research output: Contribution to journalArticlepeer-review

120 Scopus citations


Background Oral anticoagulation (OAC) with warfarin is underused for atrial fibrillation (AF). The availability of direct oral anticoagulants (DOACs) may improve overall OAC rates in AF patients, but a large-scale evaluation of their effects has not been conducted. Objectives This study assessed the effect of DOAC availability on overall OAC rates for nonvalvular AF. Methods Between April 1, 2008 and September 30, 2014, we identified 655,000 patients with nonvalvular AF and a CHA2DS2-VASc score of >1 in the National Cardiovascular Data Registry PINNACLE registry. Temporal trends in overall OAC and individual warfarin and DOAC use were analyzed. Multivariable hierarchical logistic regression identified patient factors associated with OAC and DOAC use. Practice variation of OAC and DOAC use was also assessed. Results Overall OAC rates increased from 52.4% to 60.7% among eligible AF patients (p for trend <0.01). Warfarin use decreased from 52.4% to 34.8% (p for trend <0.01), and DOAC use increased from 0% to 25.8% (p for trend <0.01). An increasing CHA2DS2-VASc score was associated with higher OAC use (odds ratio [OR]: 1.06; 95% confidence interval [CI]: 1.05 to 1.07), but with lower DOAC use (OR: 0.97; 95% CI: 0.96 to 0.98). Significant practice variation was present in OAC use (median odds ratio [MOR]: 1.52; 95% CI: 1.45 to 1.57) and in DOAC use (MOR: 3.58; 95% CI: 3.05 to 4.13). Conclusions Introduction of DOACs in routine practice was associated with improved rates of overall OAC use for AF, but significant gaps remain. In addition, there is significant practice-level variation in OAC and DOAC use.

Original languageEnglish (US)
Pages (from-to)2475-2484
Number of pages10
JournalJournal of the American College of Cardiology
Issue number20
StatePublished - May 23 2017


  • atrial fibrillation
  • direct oral anticoagulants
  • oral anticoagulation

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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