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. 2024 Mar 5;4(2):oeae016.
doi: 10.1093/ehjopen/oeae016. eCollection 2024 Mar.

Evaluating the effect of inequalities in oral anti-coagulant prescribing on outcomes in people with atrial fibrillation

Ryan J Mulholland  1 , Francesco Manca  1 , Giorgio Ciminata  1 , Terry J Quinn  1 , Robert Trotter  2 , Kevin G Pollock  3 , Steven Lister  3 , Claudia Geue  1
Affiliations

Evaluating the effect of inequalities in oral anti-coagulant prescribing on outcomes in people with atrial fibrillation

Ryan J Mulholland et al. Eur Heart J Open. .

Abstract

Aims: Whilst anti-coagulation is typically recommended for thromboprophylaxis in atrial fibrillation (AF), it is often never prescribed or prematurely discontinued. The aim of this study was to evaluate the effect of inequalities in anti-coagulant prescribing by assessing stroke/systemic embolism (SSE) and bleeding risk in people with AF who continue anti-coagulation compared with those who stop transiently, permanently, or never start.

Methods and results: This retrospective cohort study utilized linked Scottish healthcare data to identify adults diagnosed with AF between January 2010 and April 2016, with a CHA2DS2-VASC score of ≥2. They were sub-categorized based on anti-coagulant exposure: never started, continuous, discontinuous, and cessation. Inverse probability of treatment weighting-adjusted Cox regression and competing risk regression was utilized to compare SSE and bleeding risks between cohorts during 5-year follow-up. Of an overall cohort of 47 427 people, 26 277 (55.41%) were never anti-coagulated, 7934 (16.72%) received continuous anti-coagulation, 9107 (19.2%) temporarily discontinued, and 4109 (8.66%) permanently discontinued. Lower socio-economic status, elevated frailty score, and age ≥ 75 were associated with a reduced likelihood of initiation and continuation of anti-coagulation. Stroke/systemic embolism risk was significantly greater in those with discontinuous anti-coagulation, compared with continuous [subhazard ratio (SHR): 2.65; 2.39-2.94]. In the context of a major bleeding event, there was no significant difference in bleeding risk between the cessation and continuous cohorts (SHR 0.94; 0.42-2.14).

Conclusion: Our data suggest significant inequalities in anti-coagulation prescribing, with substantial opportunity to improve initiation and continuation. Decision-making should be patient-centred and must recognize that discontinuation or cessation is associated with considerable thromboembolic risk not offset by mitigated bleeding risk.

Keywords: Atrial fibrillation; Pharmacoepidemiology; Real-world data; Stroke.

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Conflict of interest statement

Conflict of interest: R.J.M., F.M., G.C., T.J.Q., and C.G. have received research grants from Bristol Myers Squibb and Pfizer UK. T.J.Q. is a data monitoring committee chair for Novo Nordisk. R.T. is currently employed by Pfizer UK and owns Pfizer stocks/shares. K.G.P. is currently employed by Bristol Myers Squibb. S.L. was previously employed by Bristol Myers Squibb and owns stocks and shares in Pfizer and Bristol Myers Squibb.

Figures

Graphical Abstract
Graphical Abstract
Figure 1
Figure 1
Outline of identification of atrial fibrillation population and formation of cohorts utilized in analyses, including sub-group analyses.
Figure 2
Figure 2
Stroke/systemic embolism risk. (A) Never started vs. discontinuous and cessation. (B) Continuous vs. discontinuous and cessation. (C) Discontinuous vs. cessation reference. Truncated upper confidence intervals: formula image16.49 formula image6.48 formula image17.75 formula image6.66 formula image8.43.
Figure 3
Figure 3
Stroke/systemic embolism risk following major bleeding event. (A) Continuous vs. cessation and discontinuous. (B) Discontinuous vs. cessation reference. Analyses were also adjusted for time off anti-coagulation.
Figure 4
Figure 4
Recurrent bleeding risk. (A) Continuous vs. cessation and discontinuous. (B) Discontinuous vs. cessation reference. Truncated upper confidence intervals: formula image11.41 formula image12.49. Analyses were also adjusted for time off anti-coagulation.
See this image and copyright information in PMC

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