Variation in anticoagulation for atrial fibrillation between English clinical commissioning groups: an observational study

Current Anticoagulation Statuses among Older Chinese People with Nonvalvular Atrial Fibrillation

Background

The reported anticoagulation rate may be overestimated among Chinese patients with atrial fibrillation (AF). Therefore, we aimed to understand the current status and time trends of anticoagulation among older people in the Chinese community.

Methods

Data were obtained from the physical examination program for the elderly (aged ≥ 65 years) in Guangzhou. During 2017-2020, a total of 31,829, 58,573, 55,483, and 54,845 older people underwent annual physical examinations, respectively, where their general information, AF-related medical history, and use of oral anticoagulants (OACs) were collected for analysis.

Results

From 2017 to 2020, the estimated annual prevalence of older people with nonvalvular atrial fibrillation (NVAF) in Guangzhou was 0.99%, 0.92%, 1.05%, and 1.14%, respectively. In patients with high stroke risk (CHA2DS2-VASc score ≥ 2 for males or ≥ 3 for females), the annual anticoagulation rates were 2.83%, 2.05%, 5.29%, and 5.82%, respectively. The proportion of NVAF patients prescribed non-vitamin K antagonist oral anticoagulants (NOACs) increased gradually over the same period (p = 0.004). Males (odds ratios (OR), 1.797; 95% confidence interval (CI), 1.169-2.763; p = 0.008), ages over 75 (OR, 1.858; 95% CI, 1.212-2.849; p = 0.005), low education levels (OR, 1.737; 95% CI, 1.132-2.665; p = 0.011), and lacking the ability for self-care (OR, 4.432; 95% CI, 1.067-18.418; p = 0.041) were less likely to receive OAC therapy.

Conclusions

The low anticoagulation rate of older people with NVAF in the Chinese community has not significantly improved in recent years, with only 5.82% of patients with high stroke risk being prescribed OACs. Therefore, it is necessary to establish an appropriate mode of anticoagulant management to improve the current situation.

Managing stroke risk in patients with atrial fibrillation: a cross-sectional analysis of socio-demographic inequalities in a London borough

BACKGROUND

Stroke prevention is essential for patients with atrial fibrillation (AF), but some receive sub-optimal management. We reviewed those with a recorded AF diagnosis assessed with CHA2DS2-VASc stroke risk score (SRS) and socio-demographic determinants of anticoagulation prescribing. The objective was to compare with national guidance recommendations, which recommend anticoagulant therapy for SRS ≥ 2, to determine if there were inequalities in management.

METHODS

A cross-sectional design was used to analyze records from all (n = 41) general practices in one London borough. Patients were excluded if they were <18 years, had AF resolved or diagnosed < 3 months. Logistic regression identified socio-demographic factors associated with high SRS and anticoagulant prescribing.

RESULTS

Of 2913 patients, 2885 (99.0%) had an SRS, and 2411 (83.6%) a score ≥ 2 and 82.9% (1999 of 2411) were prescribed anticoagulation. Women (compared with men), Black and Mixed/Multiple ethnic groups (compared with White), and those living in most deprived areas (compared with least) were more likely to have a score ≥ 2. Patients with a high SRS from Black and Mixed/Multiple ethnic groups and aged 18-74 years were less likely to be prescribed anticoagulation.

CONCLUSION

We found evidence of age and ethnic inequity in anticoagulation prescribing for stroke prevention in patients with AF.

Anticoagulation trends in adults aged 65 years and over with atrial fibrillation: a cohort study

Objective

To describe patterns of anticoagulation prescription and persistence for those aged ≥65 years with atrial fibrillation (AF).

Methods

Descriptive cohort study using electronic general practice records of patients in England, who attended an influenza vaccination aged ≥65 years and were diagnosed with AF between 2008 and 2018. Patients were stratified by 10-year age group and year of diagnosis. Proportion anticoagulated, type of anticoagulation (direct oral anticoagulant (DOAC) or warfarin) initiated at diagnosis and persistence with anticoagulation over time are reported.

Results

42 290 patients (49% female), aged 65–74 (n=11 722), 75–84 (n=19 055) and 85+ (n=11 513) years at AF diagnosis are included. Prescription of anticoagulation at diagnosis increased over the time period from 55% to 86% in people aged 65–74 years, from 54% to 86% in people aged 75–84 years and from 27% to 75% in people aged 85 years and over. By 2018, 92% of patients with newly diagnosed AF were started on a DOAC. Survivor function for 5-year persistence in patients prescribed DOAC was 0.80 (95% CI 0.77 to 0.82) and for warfarin 0.71 (95% CI 0.70 to 0.72). Survivor function for any anticoagulation at 5 years was 0.79 (95% CI 0.78 to 0.81), 0.73 (95% CI 0.72 to 0.75) and 0.58 (95% CI 0.59 to 0.64) for people aged 65–74, 75–84 and 85+ years, respectively.

Conclusions

Rates of anticoagulation in AF in those aged ≥65 years have increased from 2008 to 2018, over which time period there has been a shift from initiating anticoagulation with warfarin to DOAC. Persistence with anticoagulation is higher in people on DOACs than on warfarin and in people aged <85 years.

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

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.

Current trends in the use of anticoagulant pharmacotherapy in the United Kingdom are changes on the horizon?

INTRODUCTION

Effective stroke prevention with oral anticoagulation (OAC) reduces the risk of stroke and death among patients with atrial fibrillation (AF). For most patients with AF, treatment options include vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOACs). NOACs have been introduced as an alternative to VKAs, and their use has been steadily increasing in the United Kingdom and Europe over a decade. In randomized clinical trials, NOACs had a favorable risk-benefit profile as compared to warfarin. However, there is a concern about their long-term safety in clinical practice, especially in high-risk patients. There have been a number of registries and surveys based on the real-world patients with AF which has been conducted and published, providing data on contemporary AF management.

AREAS COVERED

In this narrative review, the authors discuss current trends in the use of OAC in the United Kingdom and Europe, considering the potential directions for future anticoagulant therapy in patients with AF.

EXPERT OPINION

The increasing prevalence of AF and AF-related comorbidities proves the need for comprehensive prevention and management strategies. The challenge is the optimization of therapy for each patient. However, there are still gaps in optimal stroke prevention, and the mortality rates remain high in patients with AF.

Trends in anticoagulant prescribing: a review of local policies in English primary care

Background

Oral anticoagulants are prescribed for stroke prophylaxis in patients with atrial fibrillation, which is the most common heart arrhythmia worldwide. The vitamin K antagonist (VKA) warfarin is a long-established anticoagulant. However, newer direct oral anticoagulants (DOACs) have been recently introduced as an alternative. Given the prevalence of atrial fibrillation, anticoagulant choice has substantial clinical and financial implications for healthcare systems. In this study, we explore trends and geographic variation in anticoagulant prescribing in English primary care. Because national guidelines in England do not specify a first-line anticoagulant, we investigate the association between local policies and prescribing data.

Methods

Primary care prescribing data of anticoagulants for all NHS practices from 2014 to 2019 in England was obtained from the ePACT2 database. Public formularies were accessed online to obtain local anticoagulation prescribing policies for 89.5% of clinical commissioning groups (CCGs). These were categorized according to their recommendations: no local policies, warfarin as first-line, or identification of a preferred DOAC (but not a preferred anticoagulant). Local policies were cross-tabulated with pooled prescribing data to measure the strength of association with Cramér’s V.

Results

Nationally, prescribing of DOACs increased from 9% of all anticoagulants in 2014 to 74% in 2019, while that of warfarin declined accordingly. Still, there was significant local variation. Across geographical regions, DOACs ranged from 53 to 99% of all anticoagulants. Most CCGs (73%) did not specify a first-line choice, and 16% recommended warfarin first line. Only 11% designated a preferred DOAC. Policies with a preferred DOAC indeed correlated with increased prescribing of that DOAC (Cramér’s V = 0.25, 0.27, 0.38 for rivaroxaban, apixaban, edoxaban respectively). However, local policies showed a negligible relationship with the classes of anticoagulants prescribed—DOAC or VKA (Cramér’s V = 0.01).

Conclusions

Nationally, the use of DOACs to treat atrial fibrillation has increased rapidly. Despite this, significant geographical variation in uptake remains. This study provides insights on how local policies relate to this variation. Our findings suggest that, in the absence of a nationally recommended first-line anticoagulant, local prescribing policies may aid in deciding between individual DOACs, but not in adjudicating between DOACs and vitamin K antagonists (i.e. warfarin) as general classes.