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. 2020 Sep 1;22(9):1311-1319.
doi: 10.1093/europace/euaa126.

Prescription of oral anticoagulants and antiplatelets for stroke prophylaxis in atrial fibrillation: nationwide time series ecological analysis

Jianhua Wu  1   2 , Eman S Alsaeed  2   3 , James Barrett  4 , Marlous Hall  2   3 , Campbell Cowan  5 , Chris P Gale  2   3   5
Affiliations

Prescription of oral anticoagulants and antiplatelets for stroke prophylaxis in atrial fibrillation: nationwide time series ecological analysis

Jianhua Wu et al. Europace. .

Abstract

Aims: To investigate trends in the prescription of oral anticoagulants (OACs) and antiplatelet agents for atrial fibrillation (AF).

Methods and results: Prescription data for 450 518 patients with AF from 3352 General Practices in England, was obtained from the GRASP-AF registry, 2009-2018. Annualized temporal trends for OAC and antiplatelet prescription were reported according to eligibility based on stroke risk (CHADS2 or CHA2DS2-VASc scores ≥1 or >2, respectively). From 2009 to 2018, the prevalence of AF increased from 1.6% [95% confidence interval (CI) 1.5-1.7%] to 2.4% (2.3-2.5%), and for those with AF the proportion prescribed OAC increased from 47.6% to 75.0% (P-trend < 0.001; relative risk 1.57, 95% CI 1.55-1.60) and for antiplatelet decreased from 37.4% to 9.2% (P-trend < 0.001). In early-years (2009-2013), eligible patients aged ≥80 years were less likely to be prescribed OAC than patients aged <80 years [odds ratio (OR) 0.55, 95% CI 0.51-0.59 for CHADS2≥1 in 2009] (all P-trends < 0.001). This 'OAC prescription gap' reduced over the study period (OR 0.93, 0.90-0.96 in 2018). Whilst the prescription of direct oral anticoagulant (DOAC) as a proportion of all OAC increased from 0.1% (95% CI 0.0-0.2%) in 2011 to 58.8% (58.4-59.2%) in 2018, it was inversely associated with patient age (P-trend < 0.001) and their risk of stroke.

Conclusion: Between 2009 and 2018, in England, the use of OAC for stroke prophylaxis in AF increased, with DOAC accounting for over half of OAC uptake in 2018. Despite a reduction in the OAC-prescription gap, a new paradox exists relating to DOAC prescription for the elderly and those at higher risk of stroke.

Keywords: Antiplatelet; Atrial fibrillation; Direct oral anticoagulants; Oral anticoagulation; Stroke.

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Figures

Figure 1
Figure 1
The temporal prevalence of AF, 2009–2018. AF, atrial fibrillation.
Figure 2
Figure 2
The temporal trend of oral anticoagulant and antiplatelet prescriptionfor patients with AF by age band and CHADS2 score, 2009–2018. AF, atrial fibrillation.
Figure 3
Figure 3
The temporal trend of oral anticoagulant and antiplatelet prescription for patients with AF by age band and CHA2DS2-VASc score, 2011–2018. AF, atrial fibrillation.
Figure 4
Figure 4
Temporals trend of the prescription of DOACs and VKA for patients with AF by CHA2DS2-VASc score, 2011–2018. AF, atrial fibrillation; DOAC, direct OAC; OAC, oral anticoagulants; VKA, vitamin K antagonists.
Figure 5
Figure 5
Temporal trends of the prescription of DOACs for patients with AF by age band, 2011–2018. AF, atrial fibrillation; DOAC, direct oral anticoagulants; VKA, vitamin K antagonists.
See this image and copyright information in PMC

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