title: Differences in anticoagulant therapy prescription in patients with paroxysmal versus persistent atrial fibrillation.
abstract: BACKGROUND
  Patients with paroxysmal and persistent atrial fibrillation experience a similar risk of thromboembolism. Therefore, consensus guidelines recommend anticoagulant therapy in those at risk for thromboembolism irrespective of atrial fibrillation classification. We sought to examine whether there are differences in rates of appropriate oral anticoagulant treatment among patients with paroxysmal vs persistent atrial fibrillation in real-world cardiology practices.
  
  
  METHODS
  We studied 71,316 outpatients with atrial fibrillation and intermediate to high thromboembolic risk (CHADS2 score ≥2) enrolled in the American College of Cardiology PINNACLE Registry between 2008 and 2012. Using hierarchical modified Poisson regression models adjusted for patient characteristics, we examined whether anticoagulant treatment rates differed between patients with paroxysmal vs persistent atrial fibrillation.
  
  
  RESULTS
  The majority of outpatients (78.4%, n = 55,905) had paroxysmal atrial fibrillation. In both unadjusted and multivariable adjusted analyses, patients with paroxysmal atrial fibrillation were less frequently prescribed oral anticoagulant therapy than those with persistent atrial fibrillation (50.3% vs 64.2%; adjusted risk ratio [RR] 0.74; 95% confidence interval [CI], 0.72-0.76). Instead, patients with paroxysmal atrial fibrillation were prescribed more frequently only antiplatelet therapy (35.1% vs 25.0%; adjusted RR 1.77; 95% CI, 1.69-1.86) or neither antiplatelet nor anticoagulant therapy (14.6% vs 10.8%; adjusted RR 1.35; 95% CI, 1.26-1.44; P < .0001 for differences across all 3 comparisons).
  
  
  CONCLUSIONS
  In a large, real-world cardiac outpatient population, patients with paroxysmal atrial fibrillation with a moderate to high risk of stroke were less likely to be prescribed appropriate oral anticoagulant therapy and more likely to be prescribed less effective or no therapy for thromboembolism prevention.
authors.affiliation: Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego. Electronic address: Jonathan.Hsu@ucsd.edu.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Hsu
authors.affiliation: Mid America Heart Institute, Kansas City, Mo.
authors.forename: Paul S
authors.initials: PS
authors.lastname: Chan
authors.affiliation: Mid America Heart Institute, Kansas City, Mo.
authors.forename: Fengming
authors.initials: F
authors.lastname: Tang
authors.affiliation: VA Eastern Colorado Health Care System/University of Colorado School of Medicine, Denver.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Maddox
authors.affiliation: Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Francisco.
authors.forename: Gregory M
authors.initials: GM
authors.lastname: Marcus
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use*; D010818:Practice Patterns, Physicians'; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000517:prevention & control; D013923:Thromboembolism / Q000517:prevention & control
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors
keywords: Anticoagulants; Atrial fibrillation; Paroxysmal; Persistent; Stroke; Thromboembolism