Abstract 12959: Practice Variation in Antiplatelet and Anticoagulation Therapy for Patients With Both Atrial Fibrillation and Coronary Artery Disease: Insights From the ACC’s PINNACLE Registry
Introduction: Recent data have shown that the risk of bleeding on dual antiplatelet therapy and oral anticoagulation (“triple therapy”) is high, although the optimal strategy for patients with indications for both therapies remains unclear.
Hypothesis: We hypothesized that in this situation, substantial practice variation exists, unrelated to measured patient factors.
Methods: We identified patient 9,538,255 patient encounters in data from the nationwide PINNACLE registry from 2008 to 2013. We included the most recent patient encounter, and identified patients with both myocardial infarction within 12 months and/or coronary stenting within 12 months and with atrial fibrillation / atrial flutter. Using those criteria, 79,875 unique patients were identified. Using intensity of anticoagulation and/or antiplatelet therapy (defining antiplatelet + anticoagulant = 3, either one = 2, and neither = 1) as an outcome variable, an ordinal logistic regression was created to determine predictors of more intense therapy. Results are presented as median odds ratio to assess practice variation after adjustment for patient factors.
Results: Both odds ratios for predictors in the model and the median odds ratio are shown in Figure 1. After adjustment for patient factors, the median odds ratio was 2.00 [1.78-2.21], suggesting significant practice variation. In particular, this suggests that two randomly selected practices would differ in their likelihood of prescribing an additional antiplatelet or anticoagulant for an identical patient by a factor of 2.
Conclusions: In this cross-section of American outpatient cardiology practices of patients with potential indications for triple therapy, there is substantial practice variation after adjusting for patient-related factors. Larger randomized trials of the various combinations of anti-platelet and anti-coagulation therapy are needed.
Author Disclosures: J.H. Wasfy: Employment; Significant; Massachusetts General Physicians Organization. Consultant/Advisory Board; Modest; QPID Health. K.F. Kennedy: None. T.G. Ferris: Honoraria; Modest; Received Speaking Honoraria. T.M. Maddox: Research Grant; Significant; VA Health Services Research and Development. R.W. Yeh: Research Grant; Significant; NHLBI, American Heart Association, Harvard Clinical Research Institute. Consultant/Advisory Board; Significant; Gilead Sciences, Abbott Vascular.
- © 2014 by American Heart Association, Inc.