Oral Anticoagulant Prescribing Trends for Stroke Prevention in Older Patients with AF

Pavankumar Kamat


September 14, 2021


  • The incidence of oral anticoagulant (OACs) prescribing for stroke prevention in older patients with atrial fibrillation (AF) was 5-fold higher in 2017 than in 2003, with disparities in prescribing based on demographics and comorbidities persisting.

  • Advancing age and dementia have been consistently linked to under-prescribing of OACs, but neither were contraindications.

Why this matters

  • National and international guidelines recommend treatment with OACs for patients with risk factors for stroke, but they have been historically underused in older patients with AF, despite advancing age being a significant risk factor for stroke.

Study design

  • A retrospective cohort study included 165,596 older patients with AF (age, ≥75 years) from the UK Clinical Practice Research Datalink (CPRD; 2003-2017).

  • All patients were categorised as:

    • no OACs (who were never prescribed OACs; n=66,859);

    • incident OACs (who were newly prescribed OACs; n=47,916); and

    • prevalent OACs (who were prescribed OACs in the year preceding study entry; n=50,821).

  • Funding: None.

Key results

  • The incidence of OAC prescribing increased from 111 per 1000 person-years in 2003 to 587 per 1000 person-years in 2017.

  • Very old patients with AF (age, ≥90 years) were 40% less likely to receive an OAC than those aged 75-84 years (risk difference [RD], −0.40; 95% CI, −0.41 to −0.39).

  • The likelihood of being prescribed an OAC was lower with (RD; 95% CI):

    • history of dementia (−0.34; −0.35 to −0.33);

    • falls (−0.17; −0.18 to −0.16);

    • major bleeding (−0.17; −0.19 to −0.15); and

    • fractures (−0.13; −0.14 to −0.12).

  • Patients were more likely to show persistence with warfarin than with direct OACs  in the first year (0-1 year: HR, 1.25; 95% CI, 1.17-1.33; 1-2 years: HR, 1.12; 95% CI, 0.99-1.28); however, the trend reversed by the third year (HR, 0.75; 95% CI, 0.63-0.89).


  • Retrospective design.


Mitchell A, Snowball J, Welsh TJ, Watson MC, McGrogan A. Prescribing of direct oral anticoagulants and warfarin to older people with atrial fibrillation in UK general practice: a cohort study. BMC Med. 2021;19(1):189. doi: 10.1186/s12916-021-02067-5. PMID: 34461899.  View full text

This clinical summary originally appeared on Univadis, part of the Medscape Professional Network.


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