AJM online Clinical research study| Volume 128, ISSUE 6, P654.e1-654.e10, June 2015

Differences in Anticoagulant Therapy Prescription in Patients with Paroxysmal Versus Persistent Atrial Fibrillation

Published:December 29, 2014DOI:



      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.


      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.


      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).


      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lloyd-Jones D.M.
        • Wang T.J.
        • Leip E.P.
        • et al.
        Lifetime risk for development of atrial fibrillation: the Framingham Heart Study.
        Circulation. 2004; 110: 1042-1046
        • Go A.S.
        • Hylek E.M.
        • Phillips K.A.
        • et al.
        Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study.
        JAMA. 2001; 285: 2370-2375
        • Hart R.G.
        • Pearce L.A.
        • Rothbart R.M.
        • McAnulty J.H.
        • Asinger R.W.
        • Halperin J.L.
        Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy. Stroke Prevention in Atrial Fibrillation Investigators.
        J Am Coll Cardiol. 2000; 35: 183-187
        • Hohnloser S.H.
        • Pajitnev D.
        • Pogue J.
        • et al.
        Incidence of stroke in paroxysmal versus sustained atrial fibrillation in patients taking oral anticoagulation or combined antiplatelet therapy: an ACTIVE W Substudy.
        J Am Coll Cardiol. 2007; 50: 2156-2161
        • Gage B.F.
        • Waterman A.D.
        • Shannon W.
        • Boechler M.
        • Rich M.W.
        • Radford M.J.
        Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation.
        JAMA. 2001; 285: 2864-2870
        • Lip G.Y.
        • Nieuwlaat R.
        • Pisters R.
        • Lane D.A.
        • Crijns H.J.
        Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.
        Chest. 2010; 137: 263-272
        • van Walraven C.
        • Hart R.G.
        • Singer D.E.
        • et al.
        Oral anticoagulants vs aspirin in nonvalvular atrial fibrillation: an individual patient meta-analysis.
        JAMA. 2002; 288: 2441-2448
        • Hart R.G.
        • Pearce L.A.
        • Aguilar M.I.
        Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.
        Ann Intern Med. 2007; 146: 857-867
        • Connolly S.J.
        • Ezekowitz M.D.
        • Yusuf S.
        • et al.
        Dabigatran versus warfarin in patients with atrial fibrillation.
        N Engl J Med. 2009; 361: 1139-1151
        • Patel M.R.
        • Mahaffey K.W.
        • Garg J.
        • et al.
        Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.
        N Engl J Med. 2011; 365: 883-891
        • Fuster V.
        • Ryden L.E.
        • Cannom D.S.
        • et al.
        ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society.
        Circulation. 2006; 114: e257-e354
        • January C.T.
        • Wann L.S.
        • Alpert J.S.
        • et al.
        2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        Circulation. 2014; 130: 2071-2104
        • Chan P.S.
        • Maddox T.M.
        • Tang F.
        • Spinler S.
        • Spertus J.A.
        Practice-level variation in warfarin use among outpatients with atrial fibrillation (from the NCDR PINNACLE program).
        Am J Cardiol. 2011; 108: 1136-1140
        • Go A.S.
        • Hylek E.M.
        • Borowsky L.H.
        • Phillips K.A.
        • Selby J.V.
        • Singer D.E.
        Warfarin use among ambulatory patients with nonvalvular atrial fibrillation: the anticoagulation and risk factors in atrial fibrillation (ATRIA) study.
        Ann Intern Med. 1999; 131: 927-934
        • Reynolds M.R.
        • Shah J.
        • Essebag V.
        • et al.
        Patterns and predictors of warfarin use in patients with new-onset atrial fibrillation from the FRACTAL Registry.
        Am J Cardiol. 2006; 97: 538-543
        • Gallagher A.M.
        • Rietbrock S.
        • Plumb J.
        • van Staa T.P.
        Initiation and persistence of warfarin or aspirin in patients with chronic atrial fibrillation in general practice: do the appropriate patients receive stroke prophylaxis?.
        J Thromb Haemost. 2008; 6: 1500-1506
        • Chan P.S.
        • Oetgen W.J.
        • Buchanan D.
        • et al.
        Cardiac performance measure compliance in outpatients: the American College of Cardiology and National Cardiovascular Data Registry's PINNACLE (Practice Innovation And Clinical Excellence) program.
        J Am Coll Cardiol. 2010; 56: 8-14
        • Chan P.S.
        • Oetgen W.J.
        • Spertus J.A.
        The Improving Continuous Cardiac Care (IC(3)) program and outpatient quality improvement.
        Am J Med. 2010; 123: 217-219
        • Harrell F.E.
        Regression Modeling Strategies: With Applications to Linear Models, Logistic Regression, and Survival Analysis.
        Springer, New York2001
        • Raghunathan T.E.
        • Solenberger P.W.
        • Van Hoewyk J.
        IVEware: Imputation and Variance Estimation Software.
        Survey Methodology Program, Survey Research Center, Institute for Social Research, University of Michigan, Ann Arbor, MI2002
        • Greenland S.
        Model-based estimation of relative risks and other epidemiologic measures in studies of common outcomes and in case-control studies.
        Am J Epidemiol. 2004; 160: 301-305
        • Zou G.
        A modified poisson regression approach to prospective studies with binary data.
        Am J Epidemiol. 2004; 159: 702-706
        • Healey J.S.
        • Connolly S.J.
        • Gold M.R.
        • et al.
        Subclinical atrial fibrillation and the risk of stroke.
        N Engl J Med. 2012; 366: 120-129
        • Waldo A.L.
        • Becker R.C.
        • Tapson V.F.
        • Colgan K.J.
        Hospitalized patients with atrial fibrillation and a high risk of stroke are not being provided with adequate anticoagulation.
        J Am Coll Cardiol. 2005; 46: 1729-1736
        • Nieuwlaat R.
        • Capucci A.
        • Lip G.Y.
        • et al.
        Antithrombotic treatment in real-life atrial fibrillation patients: a report from the Euro Heart Survey on Atrial Fibrillation.
        Eur Heart J. 2006; 27: 3018-3026
        • Glazer N.L.
        • Dublin S.
        • Smith N.L.
        • et al.
        Newly detected atrial fibrillation and compliance with antithrombotic guidelines.
        Arch Intern Med. 2007; 167: 246-252
        • Connolly S.
        • Pogue J.
        • Hart R.
        • et al.
        Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial.
        Lancet. 2006; 367: 1903-1912
        • Olesen J.B.
        • Torp-Pedersen C.
        • Hansen M.L.
        • Lip G.Y.
        The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score 0-1: a nationwide cohort study.
        Thromb Haemost. 2012; 107: 1172-1179