Black Patients with AF Often Don't Receive Anticoagulant at Hospital Discharge, Study Suggests

Black patients hospitalized with atrial fibrillation were 25% less likely to receive oral anticoagulants upon discharge according to a large national registry study.

Black patients hospitalized for atrial fibrillation (AF) were 25% less likely than White patients to be prescribed any oral anticoagulant (OAC) at hospital discharge and experienced higher rates of stroke, bleeding, and death 1 year later, according to results of new research presented at Heart Rhythm 2022, the annual meeting of the Heart Rhythm Society (HRS).

Patients with AF have a 5-fold greater risk of stroke, according to the Centers for Disease Control and Prevention, risk that can be significantly reduced with OAC treatment. Study investigators led by Utibe R. Essien, MD, MPH, assistant professor of medicine at the University of Pittsburgh School of Medicine, were interested to see if prescribing rates of OAC differ by race/ethnicity in patients discharged after AF hospitalization and how any differences may affect inequities in AF outcomes.

Essien and colleagues tapped the American Heart Association’s Get with the Guidelines-AFib, a national quality improvement initiative that collects data related to patients hospitalized with AF, including use of guideline-directed medical therapy. Reviewing data from 2014-2020, the investigators evaluated 69 553 patients hospitalized with AF from 159 medical centers. Mean age of the cohort was 68.6 years; 7.3% were Black, 5.8% Hispanic, 1.2% Asian, and 85.6% White; mean CHADS2VA2Sc score was 3.8.

The primary outcome of interest was presence of OAC at discharge according to race/ethnicity. Secondary outcomes, based on Medicare linkage data, included incidence of ischemic stroke, bleeding, or all-cause mortality at 1-year post-discharge, also by race/ethnicity.

Inequities in findings

Overall, the study team found, 78.5% of patients were discharged on any OAC.

Analysis by race/ethnicity, adjusted for demographics, medical history, admission year, socioeconomic status, and specific hospital, revealed that Black patients were 25% less likely to receive any OAC at discharge vs White patients (aOR, 0.75 [95% CI, 0.67-0.84]) and Black patients who were discharged on OAC were 18% less likely to receive direct oral anticoagulants vs warfarin (aOR, 0.82 [95% CI, 0.65-0.96]).

Modeling of secondary outcomes using Cox proportional hazard regression with variance estimation found that Black patients had higher rates of bleeding (aOR 2.08 [95% CI, 1.5-2.8]), stroke (aOR 2.07 [95% CI, 1.34-3.20]), and mortality (aOR, 1.22 [95% CI, 1.02-1.47]). Secondary outcomes among Hispanic patients, Essein et al found, also pointed to higher stroke rates at 1-year vs White patients (aOR, 2.02 [95% CI, 1.38-2.95]).

“Our findings show that racial disparities exist in ongoing, follow-up care for atrial fibrillation, which are in-turn, negatively impacting patient outcomes. Now, we must get to the root of the issue and understand what factors are driving these differences,” said author Essien in a HRS press release. “Every patient, regardless of race or ethnicity, deserves the chance to have life-saving treatment and we must work together to deliver equitable, compassionate care.”

“Every patient, regardless of race or ethnicity, deserves the chance to have life-saving treatment and we must work together to deliver equitable, compassionate care.”

In their conclusion the authors suggest that the higher cost of direct oral anticoagulants vs warfarin may be among the drivers of racial/ethnic disparities in OAC prescribing and that better understanding of “the root of the issue” will help guide interventions toward more equitable AF care.

Reference: Essein UR, Kaltenbach L, Want T, et al. Racial and ethnic inequities in oral anticoagulation and associated outcomes for patients with atrial fibrillation – the Get with the Guidelines Atrial Fibrillation Registry. Heart Rhythm. 2022;19:S87-88.