Use of Guideline-Directed Medical Therapies For Comorbidities and Atrial Fibrillation

Use of Guideline-Directed Medical Therapies For Comorbidities and Atrial Fibrillation


What we did with this project was to evaluate
the use of guideline directed medical therapy for comorbid conditions in
patients with atrial fibrillation. We know that atrial fibrillation is a growing
problem in the US and that it is frequently coexistent with other cardiac comorbidities such
as CAD, diabetes, hypertension, high cholesterol and we were interested in both how well those
commodities are treated in AFib patients and what the association between treatment of
those comorbidities is on outcomes. So we looked at a registry of ambulatory AFib
patients in the US, called the ORBIT-AF registry, which has more than 20,000 patients in it,
and we evaluated patients who had had an additional comorbidity for which there’s professional
guidelines for evidence-based therapies. And then we looked at the rates of those therapies
as well as the association between those therapies and clinical outcomes. Some of the key findings that we found in
this study were that two thirds of patients are not on all the medical therapies for which
they’re indicated, only about 33 percent are. That’s a little bit lower than
I think we had expected. Based on prior studies we thought it was probably
closer to 40 or 50 percent, but that’s pretty substantially lower than that. Adherence to different guideline directed
medical therapies varied based on which comorbidity you were looking at. Hyperlipidemia, for instance, had more than
70 percent of patients appropriately treated with statins, whereas diabetes patients were
only treated with all of their eligible therapies 43 percent of the time. The other interesting aspect of this project
was instead of just looking at the prevalence of GDMT, or guideline directed medical therapy
use, we also related them to outcomes, and so we looked at the association between being
on all of the therapies for which you’re eligible and different clinical outcomes, including
all-cause mortality, MACNE, which stands for major adverse cardiac or neurovascular events,
cardiovascular hospitalizations, as well as progression of atrial fibrillation. Looking at the outcomes analyses, we found
that there was a trend towards lower events of all-cause mortality and MACNE, or major
adverse cardiac or neurovascular events, with use of all eligible medical therapies, but
they didn’t quite meet statistical significance. To explore this further we broke down the
use of GDMT by comorbidity and we looked at all the outcomes within each comorbidity group. The treatment with GDMT for heart failure
specifically was associated with a 23 percent reduction in all-cause mortality that was
highly statistically significant, and that’s really interesting because it tells us that
there’s an interaction between the comorbidities and outcomes with atrial fibrillation patients,
and specifically this relationship between atrial fibrillation and heart failure is really
interesting in the context of some of the other data showing that catheter ablation
for atrial fibrillation may improve outcomes amongst heart failure patients and it makes
us kind of think about the interrelationship between those different conditions. Treating one has effect on
the outcomes of the other. We also noticed that for patients with obstructive
sleep apnea, use of CPAP, or continuous positive airway pressure, was associated with a reduction
in the progression of atrial fibrillation from paroxysmal atrial fibrillation to persistent. This is something we’ve heard a little bit
about in the literature, that treatment with CPAP for OSA patients can help reduce the
symptom burden and progression of atrial fibrillation, and it was reassuring to see
those results in this analysis. I think that when you look at the trends of
who gets all the therapies that they’re eligible for we see that there’s discrepancies, as
we’ve seen in many other large registry datas where men tend to get better, get more of
the treatments for which they’re eligible, as well as people of white race. This is consistent with many of the other
large registry datas that show that there are discepencies in treatment patterns, but it
also may be reflective of difference in disease severity. We noticed that the people who are on all
eligible therapies also had fewer of the comorbidities that we were evaluating, so they were in
general kind of a less sick population, and it may be that their physicians felt more comfortable
prescribing them more therapies, or all the therapies that they were eligible compared
to a sicker patient for which you may want to move slower and more gradually with. I think that the overall evidence suggests
that if you can get someone on all of the medications that they’re eligible
for they will have a better outcome. Now, this is a retrospective observational
study, so we can’t make any causal claim saying that the use of these medicinces is driving the
outcomes, we just can comment on the association of them, but I think that when we break it
down by comorbidity we see the importance of, certain conditions are highlighted, for
example, heart failure where we see an association between the use of guideline directed
medical therapy and outcomes.

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