title: Oral Anticoagulant Therapy Prescription in Patients With Atrial Fibrillation Across the Spectrum of Stroke Risk: Insights From the NCDR PINNACLE Registry.
abstract: Patients with atrial fibrillation (AF) are at a proportionally higher risk of stroke based on accumulation of well-defined risk factors.
  
  
  
  To examine the extent to which prescription of an oral anticoagulant (OAC) in US cardiology practices increases as the number of stroke risk factors increases.
  
  
  
  Cross-sectional registry study of outpatients with AF enrolled in the American College of Cardiology National Cardiovascular Data Registry's PINNACLE (Practice Innovation and Clinical Excellence) Registry between January 1, 2008, and December 30, 2012. As a measure of stroke risk, we calculated the CHADS2 score and the CHA2DS2-VASc score for all patients. Using multinomial logistic regression models adjusted for patient, physician, and practice characteristics, we examined the association between increased stroke risk score and prescription of an OAC.
  
  
  
  The primary outcome was prescription of an OAC with warfarin sodium or a non-vitamin K antagonist OAC.
  
  
  
  The study cohort comprised 429 417 outpatients with AF. Their mean (SD) age was 71.3 (12.9) years, and 55.8% were male. Prescribed treatment consisted of an OAC (192 600 [44.9%]), aspirin only (111 134 [25.9%]), aspirin plus a thienopyridine (23 454 [5.5%]), or no antithrombotic therapy (102 229 [23.8%]). Each 1-point increase in risk score was associated with increased odds of OAC prescription compared with aspirin-only prescription using the CHADS2 score (adjusted odds ratio, 1.158; 95% CI, 1.144-1.172; P < .001) and the CHA2DS2-VASc score (adjusted odds ratio, 1.163; 95% CI, 1.157-1.169; P < .001). Overall, OAC prescription prevalence did not exceed 50% even in higher-risk patients with a CHADS2 score exceeding 3 or a CHA2DS2-VASc score exceeding 4.
  
  
  
  In a large quality improvement registry of outpatients with AF, prescription of OAC therapy increased with a higher CHADS2 score and CHA2DS2-VASc score. However, a plateau of OAC prescription was observed, with less than half of high-risk patients receiving an OAC prescription.
authors.affiliation: Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Hsu
authors.affiliation: Division of Cardiology, Department of Medicine, Veterans Affairs Eastern Colorado Health Care System, Denver3Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Denver4Division of Cardiology, Department of Medicine.
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Maddox
authors.affiliation: Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
authors.forename: Kevin F
authors.initials: KF
authors.lastname: Kennedy
authors.affiliation: Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Denver.
authors.forename: David F
authors.initials: DF
authors.lastname: Katz
authors.affiliation: Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Denver.
authors.forename: Lucas N
authors.initials: LN
authors.lastname: Marzec
authors.affiliation: Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston.
authors.forename: Steven A
authors.initials: SA
authors.lastname: Lubitz
authors.affiliation: Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill.
authors.forename: Anil K
authors.initials: AK
authors.lastname: Gehi
authors.affiliation: Division of Cardiology, Department of Medicine, Veterans Affairs Palo Alto Health Care System, Palo Alto, California9Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.
authors.forename: Mintu P
authors.initials: MP
authors.lastname: Turakhia
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: D000284:Administration, Oral; D000368:Aged; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D001281:Atrial Fibrillation / Q000188:drug therapy*; D000075203:Contraindications, Drug; D005260:Female; D006801:Humans; D008297:Male; D012042:Registries; D012306:Risk; D020521:Stroke / Q000139:chemically induced* / Q000517:prevention & control
chemical_list: D000925:Anticoagulants