General practitioners (GPs) undertreat women with atrial fibrillation (AF), according to research presented at ESC Congress 2013 today by Dr Pierre Sabouret from France. The analysis of more than 15,000 patients showed that women were undertreated with antithrombotic medications compared to men regardless of their stroke risk and comorbidities.
Dr Sabouret said: "Gender-related differences among outpatients with stable coronary artery disease are well known.1-6 Heart diseases are one of the most important causes of death among women worldwide.5 Therefore, it's crucial that women benefit from optimal treatments according to guidelines."
In France both the prevalence (600,000 to 1 million patients) and incidence (110,000 to 230,000 new cases per year) of AF are dramatically increasing.7 ESC AF guidelines recommend the CHA2DS2-VASc score to determine stroke risk and the need for anticoagulation to prevent stroke.8 Female gender is a specific risk and adds one point to the stroke risk score. However no antithrombotic treatment is required if the patient is female, <65 years old and has lone AF.
Dr Sabouret said: "To improve the cardiovascular prognosis of women with AF it's important to know if there are any gender differences in management. Many AF patients are treated by GPs so we studied their practise."
The current study investigated the management of AF patients by GPs in France with a focus on gender differences. The aim was to identify potential factors in the choice of prescription (vitamin K antagonist [VKA] alone, aspirin alone or no oral anticoagulants), particularly patient characteristics, disease characteristics, medical history and concomitant medications.
A total of 15,623 AF patients aged ≥18 years were identified from the Longitudinal Patient Database (LPD) during 1 July 2010 to 30 June 2011. The LPD (set up in 1994) contains information on medical history, comorbidities and concomitant medication in 1.6 million active patients from a representative sample of 1,200 active GPs in France. The multivariate analyses included 14,274 patients after excluding those on clopidogrel. Median age was 77 years old, 41.6% were women and 93.2% had a CHA2DS2-VASc score >1.
After excluding women ineligible for anticoagulation (CHA2DS2-VASc score of 1 and age <65 years) the researchers found that women were significantly less treated than men. Just 48.1% of women received VKA (vs 52.6% men) (p<0.0001) and 30.5% received no prevention at all (vs 25.4% men) (p<0.0001). More than 21% received only aspirin despite guideline recommendations that they should receive VKA.
Dr Sabouret said: "Women with AF receive less anticoagulation treatment than men despite the fact that they are at greater risk of stroke. The new CHA2DS2-VASc score should be used more stringently, especially in women, to optimise their treatment. Treatment of all women with AF should be reviewed to ensure they are receiving anticoagulation if appropriate according to the CHA2DS2-VASc score."
Age-stratified multivariate analysis* of VKA prescription in patients <75 years found women were half as likely to be treated as men (odds ratio [OR]=0.56, 95% confidence interval [CI]=0.48-0.65) (p<0.0001). In the >75 years subgroup women were 33% less likely to be treated than men (OR=0.67, 95% CI=0.60-0.75) (p<0.0001).
Dr Sabouret concluded: "Women with AF are undertreated compared with men regardless of their stroke risk and comorbidities. This study has revealed a significant gap between guidelines and practice and requires GPs and cardiologists to work together to optimise treatment for women."