Evolving landscape of stroke prevention in atrial fibrillation within the UK between 2012 and 2016: a cross-sectional analysis study using CPRD

Abstract

ObjectiveTo describe the changes in prescribing of oral anticoagulant (AC) and antiplatelet (AP) agents in patients with non-valvular atrial fibrillation (NVAF) in the UK and to identify the characteristics associated with deviation from guideline-based recommendations.DesignFive cross-sectional analyses in a large retrospective population-based cohort study.SettingGeneral practices contributing data to the UK Clinical Practice Research Datalink.ParticipantsThe study included patients with a diagnosis of NVAF and eligible for anticoagulation (CHA2DS2-VASc score ≥2) on 1 April of 2012, 2013, 2014, 2015 and 1st January 2016.ResultsThe proportion of patients being treated with AC increased at each index date, showing an absolute rise of 16.7% over the study period. At the same time, the proportion of patients treated with an AP alone was reduced by half, showing an absolute decrease of 16.8%. The proportion of patients not receiving any antithrombotic (AT) treatment remained the same across the study period. A number of predictors were identified for AP alone or no treatment compared with AC treatment.ConclusionMajor improvements in the AT management of patients with NVAF for stroke prevention in the UK were observed between April 2012 and January 2016. Despite this, nearly 20% of at-risk patients still received AP alone and over 15% were on no AT agents in January 2016.

Temporal variation in the diagnosis of resolved atrial fibrillation and the influence of performance targets on clinical coding: cohort study

“…In 2016, 79.5% of patients with ‘resolved AF’ and a CHA 2 DS 2 -VASc score ≥1 were not prescribed anticoagulants at the time of their ‘resolved AF’ diagnosis, made up of 53.5% who had never been prescribed anticoagulants and 26.0% who had previously been prescribed anticoagulants but had subsequently discontinued. By contrast, only 25%–30% of patients with ongoing AF and a CHA 2 DS 2 -VASc score ≥1 were not prescribed anticoagulants in 2016 8 16. This suggests that patients with AF who are not prescribed anticoagulants may be more likely to be assigned a ‘resolved AF’ code.…”

International normalised ratio monitoring in the community populations of the Auckland and Northland regions of New Zealand: time in therapeutic range and frequency of testing

“…Recently, dabigatran has been available for a wider range of indications, so patients are less likely to be initiated on warfarin. However, the number of INR requests at our laboratory has only fallen by 10% since dabigatran became more available, so it is likely that there will be a cohort of patients on warfarin but eligible for the newer agent due to prescriber inertia . It may be that there are patients in our communities with poorer control that would benefit from switching from warfarin to dabigatran…”

“…However, the number of INR requests at our laboratory has only fallen by 10% since dabigatran became more available, so it is likely that there will be a cohort of patients on warfarin but eligible for the newer agent due to prescriber inertia. 1 It may be that there are patients in our communities with poorer control that would benefit from switching from warfarin to dabigatran. 16 Our patient cohort had a slightly lower TTR (63% vs 67%) than that reported in a recent NZ study in which patients were managed by their general practitioner using decision-support software.…”

“…The availability of direct‐acting anticoagulant drugs such as dabigatran has substantially changed the management of patients at risk of thrombotic diseases. Despite this, warfarin remains in common use, particularly among patients where treatment was initiated prior to the availability of the newer drugs . In New Zealand (NZ), it has been estimated that 35 000 people will be on treatment at any given time, predominantly patients with atrial fibrillation, venous thromboembolism and prosthetic cardiac valves …”

“…Despite this, warfarin remains in common use, particularly among patients where treatment was initiated prior to the availability of the newer drugs. 1 In New Zealand (NZ), it has been estimated that 35 000 people will be on treatment at any given time, predominantly patients with atrial fibrillation, venous thromboembolism and prosthetic cardiac valves. 2,3 The anticoagulant effect of warfarin is affected by concomitant medications, diet and co-existing comorbidities, which can influence clotting tendency, potentially resulting in life-threatening complications such as bleeding or thrombosis.…”