Incidence of nonvalvular atrial fibrillation and oral anticoagulant prescribing in England, 2009 to 2019: A cohort study
<h4>Background</h4> Atrial fibrillation (AF) is an important risk factor for ischaemic stroke, and AF incidence is expected to increase. Guidelines recommend using oral anticoagulants (OACs) to prevent the development of stroke. However, studies have reported the frequent underuse of OAC...
| Main Authors: | , , , , , , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Public Library of Science (PLoS)
2022-06-01
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| Series: | PLoS Medicine |
| Online Access: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9173622/?tool=EBI |
| Summary: | <h4>Background</h4> Atrial fibrillation (AF) is an important risk factor for ischaemic stroke, and AF incidence is expected to increase. Guidelines recommend using oral anticoagulants (OACs) to prevent the development of stroke. However, studies have reported the frequent underuse of OACs in AF patients. The objective of this study is to describe nonvalvular atrial fibrillation (NVAF) incidence in England and assess the clinical and socioeconomic factors associated with the underprescribing of OACs. <h4>Methods and findings</h4> We conducted a population-based retrospective cohort study using the UK Clinical Practice Research Datalink (CPRD) database to identify patients with NVAF aged ≥18 years and registered in English general practices between 2009 and 2019. Annual incidence rate of NVAF by age, deprivation quintile, and region was estimated. OAC prescribing status was explored for patients at risk for stroke and classified into the following: OAC, aspirin only, or no treatment. We used a multivariable multinomial logistic regression model to estimate relative risk ratios (RRRs) and 95% confidence intervals (CIs) of the factors associated with OAC or aspirin-only prescribing compared to no treatment in patients with NVAF who are recommended to take OAC. The multivariable regression was adjusted for age, sex, comorbidities, socioeconomic status, baseline treatment, frailty, bleeding risk factors, and takes into account clustering by general practice. Between 2009 and 2019, 12,517,191 patients met the criteria for being at risk of developing NVAF. After a median follow-up of 4.6 years, 192,265 patients had an incident NVAF contributing a total of 647,876 person-years (PYR) of follow-up. The overall age-adjusted incidence of NVAF per 10,000 PYR increased from 20.8 (95% CI: 20.4; 21.1) in 2009 to 25.5 (25.1; 25.9) in 2019. Higher incidence rates were observed for older ages and males. Among NVAF patients eligible for anticoagulation, OAC prescribing rose from 59.8% (95% CI: 59.0; 60.6) in 2009 to 83.2% (95% CI: 83.0; 83.4) in 2019. Several conditions were associated with lower risk of OAC prescribing: dementia [RRR 0.52 (0.47; 0.59)], liver disease 0.58 (0.50; 0.67), malignancy 0.74 (0.72; 0.77), and history of falls 0.82 (0.78; 0.85). Compared to white ethnicity, patients from black and other ethnic minorities were less likely to receive OAC; 0.78 (0.65; 0.94) and 0.76 (0.64; 0.91), respectively. Patients living in the most deprived areas were less likely to receive OAC 0.85 (0.79; 0.91) than patients living in the least deprived areas. Practices located in the East of England were associated with higher risk of prescribing aspirin only over no treatment than practices in London (RRR 1.22; 95% CI 1.02 to 1.45). The main limitation of this study is that these findings depends on accurate recording of conditions by health professionals and the inevitable residual confounding due to lack of data on certain factors that could be associated with under-prescribing of OACs. <h4>Conclusions</h4> The incidence of NVAF increased between 2009 and 2015, before plateauing. Underprescribing of OACs in NVAF is associated with a range of comorbidities, ethnicity, and socioeconomic factors, demonstrating the need for initiatives to reduce inequalities in the care for AF patients. Alyaa Ajabnoor and co-workers study incidence of non-valvular atrial fibrillation in England and apparent inequalities in care. Author summary <h4>Why was this study done?</h4> Previous research has shown that the incidence of atrial fibrillation (AF) is expected to increase, although limited data exists in the UK. AF is one of the most important risk factors for future stroke risk, and the treatment of choice is anticoagulation. Many patients with nonvalvular atrial fibrillation (NVAF) are not receiving anticoagulant therapy for stroke prevention, although it remains uncertain whether there is an association with patient ethnicity and socioeconomic status. <h4>What did the researchers do and find?</h4> We used electronic health records from GP practices in England to estimate the incidence of NVAF between the 2009 and 2019. We have also explored the clinical and socioeconomic factors associated with prescribing oral anticoagulants (OACs). We have found that the incidence of NVAF in England has increased during the past decade and plateaued from 2015 onwards. There are racial and socioeconomic inequalities in the prescribing of OACs in England, with low socioeconomic status and black or other non-white ethnicities associated with the prescription of aspirin only or no treatment compared to white patients or those with higher socioeconomic status. <h4>What do these findings mean?</h4> There are many patients at risk for stroke who are not receiving anticoagulants, and clinical and sociodemographic factors play a role in the underprescribing of OACs Our findings suggest that, in order to improve AF outcomes, these inequalities need to be addressed through equitable interventions to improve OAC prescribing to prevent stroke events and reduce mortality. |
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| ISSN: | 1549-1277 1549-1676 |