Abstract Body: Objective: To examine how social vulnerability and unmet social needs affect direct oral anticoagulant (DOAC) use among reproductive-aged women with atrial fibrillation and flutter (AF/AFL).
Background: Reproductive-aged women face greater healthcare costs and cost-related barriers than men. With the increasing rates of AF/AFL in this population, it is essential to investigate social factors that limit the optimal use of DOACs in this understudied population.
Methods: We analyzed 3,755 women aged 18–50 with AF/AFL from the 2013-2024 AHA Get With The Guidelines–AF registry. Unmet social needs (socioeconomic, behavioral health, health insurance, community/environment) were assessed and used to classify levels of social vulnerability (ranked by the number of unmet needs: no (0), mild (1), and moderate to severe (mod-sev, ≥2). Mean CHA₂DS₂VASc scores and odds of DOAC treatment were compared across social vulnerability levels, with adjustments for age, race/ethnicity, and comorbidities (renal impairment, liver disease, and mechanical valves).
Results: Among the 3,755 women with AF/AFL, the mean age was 43 years, 65% were white, 21% were black, 8% were Hispanic, and 6% other races. About 34% lacked or had public health insurance, 2% had behavioral health needs, 0.7% had community/environmental needs, and 1% had socioeconomic needs. Overall, 65.4% had no social vulnerability, 33% had mild vulnerability, and 1% had mod-sev vulnerability (Table). Mean CHA₂DS₂VASc scores increased with increasing levels of vulnerability (no: 2.09 (SD 1.13); mild: 2.68 (SD 1.30); mod-sev: 2.90 (SD 1.43, p < 0.005). Women with mild vulnerability were 47% less likely to be treated with a DOAC (OR 0.53, 95% CI: 0.42, 0.66) compared to those with no social vulnerability, which remained similar after adjustment (OR 0.56, 95% CI: 0.44, 0.70). Though not statistically significant, there was a trend toward lower DOAC use in the mod-sev group (OR 0.75, 95% CI: 0.33, 1.69).
Conclusion: The increasing trend in CHA₂DS₂VASc scores across increasing social vulnerability highlights how those with higher social vulnerability have a greater burden of AF/AFL-related comorbidities. Although few women with AF/AFL had higher levels of social vulnerability, many with mild social vulnerability were less likely to receive DOACs despite guideline recommendations. Addressing unmet social needs, particularly health insurance, will likely enhance equitable healthcare access for this population.