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

AbstractObjectiveTo describe patterns of anticogulation prescribing and persistence for those aged ≥65 years with atrial fibrillation (AF).MethodsDescriptive cohort study using electronic general practice records of patients in England who attended a flu vaccination aged ≥65, and were diagnosed with AF between 2008-2018. 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.Results42,290 patients (49% female), aged 65-74 (n=11,722), 75-84 (n=19,055) and 85+ (n=11,513) at AF diagnosis are included. Prescription of anticoagulation at diagnosis increased over the time period from 55% to 86% in people aged 65-74, from 54% to 86% in people aged 75-84 and from 27% to 75% in people aged 85 and over. No patients were prescribed DOACs as a first anticoagulation agent in 2008, by 201892% of new AF patients were started on DOACs. Survivor function for 5 year persistence for patients taking only a single type of anticoagulant was 0.80 (0.77:0.82) for DOACs and0.71(0.70:0.72) for warfarin, Survivor function for any anticoagulation at 5 years was0.79(0.78:0.81), 0.73(0.72:0.75), 0.58(0.59:0.64) for people aged 65-74, 75-84 and 85+ respectively.ConclusionsRates of anticoagulation for new AF in those aged ≥65 have increased from 2008 to 2018, over which time there has been a shift from initiating anticoaguation with warfarin to DOACs. Persistence with anticoagulation is higher in people on DOACs than on warfarin, and in people under the aged of 85.Key MessagesWhat is already known?Anticoagulation is a highly effective way of reducing the risk of stroke associated with AF, but is underused, particularly in older people. The introduction of DOACs has been associated with increasing use of anticoagulation in AF.What does this study add?Our study provides up to date information on anticoagulation for AF in older people who are most at risk of AF related stroke and highlights particular increases in use of anticoagulation in people aged 85 and over.DOACs are now the major class of anticoagulant prescribed to patients with new AF in UK general practice.Long term persistence with anticoagulation is higher with DOACs than warfarin, but drops in all age groups over 5 years.How might this impact on clinical practice?Improved uptake of anticoagulation at all ages removes one of the potential barriers to screening for atrial fibrillation, but new strategies may be needed to enhance longer term persistence with treatment.

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

Open Heart ◽

10.1136/openhrt-2021-001737 ◽

2021 ◽

Vol 8 (2) ◽

pp. e001737

Author(s):

Jenny Lund ◽

Catherine L Saunders ◽

Duncan Edwards ◽

Jonathan Mant

Keyword(s):

Atrial Fibrillation ◽

General Practice ◽

Cohort Study ◽

Oral Anticoagulant ◽

Age Group ◽

Direct Oral Anticoagulant ◽

Newly Diagnosed ◽

Survivor Function ◽

Time Period ◽

Over Time

ObjectiveTo describe patterns of anticoagulation prescription and persistence for those aged ≥65 years with atrial fibrillation (AF).MethodsDescriptive 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.Results42 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.ConclusionsRates 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.

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Use of oral anticoagulants in older people with atrial fibrillation in UK general practice: protocol for a cohort study using the Clinical Practice Research Datalink (CPRD) database

BMJ Open ◽

10.1136/bmjopen-2019-032646 ◽

2019 ◽

Vol 9 (12) ◽

pp. e032646

Author(s):

Anneka Mitchell ◽

Tomas J Welsh ◽

Margaret C Watson ◽

Julia Snowball ◽

Anita McGrogan

Keyword(s):

Atrial Fibrillation ◽

General Practice ◽

Cohort Study ◽

Clinical Practice ◽

Older People ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Practice Research ◽

Clinical Practice Research Datalink ◽

Standard Data

IntroductionWarfarin has frequently been underused in older people for stroke prevention in atrial fibrillation (AF). Direct oral anticoagulants (DOACs) entered the UK market from 2008 and have been recommended as an alternative to warfarin. This study aimed to describe any changes in the prescribing of oral anticoagulants (OACs) to people aged ≥75 years in UK general practice before and after the introduction of DOACs, to examine differences in patient characteristics which may influence prescribers’ decisions regarding anticoagulation, to evaluate the time people stay on OACs and switching between OACs.Methods and analysisA retrospective cohort study design will be used. Patients with a diagnosis of AF will be identified from the Clinical Practice Research Datalink (CPRD). The study period will run from 1 January 2003 to 27 December 2017. Patients enter the cohort at the latest date of the start of the study period, first AF diagnosis, 75th birthday or a year from when they started to contribute research standard data. Follow-up continues until they leave the practice, death, the date the practice stops contributing research standard data or the end of the study period (27 December 2017). Exposure to OACs will be defined as ≥1 prescription issued for an OAC of interest during the study period. Patients issued an OAC in the year preceding study entry will be defined as ‘prevalent users’. Patients starting on an OAC during the study period will be defined as ‘incident users’. Incidence and prevalence of OAC prescribing, patient demographics and characteristics will be described during three time periods: 2003–2007, 2008–2012 and 2013–2017. Persistence (defined as the time from initiation to discontinuation of medication) with and switching between different OACs will be described.Ethics and disseminationThe protocol for this study was approved by the CPRD Independent Scientific Advisory Committee. The results will be disseminated in a peer-reviewed journal and at conferences.Trial registration numberEUPAS29923.

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A.07 Characterizing the epidemiology of epilepsy in Saskatchewan, Canada

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2018.88 ◽

2018 ◽

Vol 45 (s2) ◽

pp. S11-S11

Author(s):

L Hernandez Ronquillo ◽

L Thorpe ◽

P Pahwa ◽

J Tellez Zenteno

Keyword(s):

Cohort Study ◽

Age Groups ◽

Population Based ◽

Secular Trends ◽

Health Administrative Data ◽

Time Period ◽

Canadian Population ◽

Incidence And Mortality ◽

All Cause Mortality ◽

Icd Codes

Background: There is no available estimate of the incidence and mortality of epilepsy in all age groups in the Canadian population. This study aimed to measure the incidence, prevalence, mortality and the secular trends for epilepsy in Saskatchewan between 2005 and 2010. Methods: A population-based cohort study was established from Saskatchewan’s provincial health administrative data. The population was followed until termination of coverage, death, or 31 December 2010. Individuals with epilepsy were identified based on ICD codes algorithms from 2005 to 2010. Results: The age-standardized incidence of epilepsy was 62 per 100,000 person-year. The age-standardized incidence rate of epilepsy in self-declared Registered Indians was 122 per 100,000 person-year. There was a significant decrease in the incidence of epilepsy for all groups over the study period. The age-standardized prevalence of epilepsy was 9 per 1,000 people. There was a significant increase in the prevalence of epilepsy over this time period. The adjusted mortality rate was 0.023 per 1000 person-year, and the all-cause Standardized Mortality Ration for epilepsy was 2.45. The SMR remained constant over the six-year period of the study. Conclusions: This study is the first in Canada to measure the incidence and all-cause mortality of epilepsy in all age groups.

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Performance of stroke risk scores in older people with atrial fibrillation not taking warfarin: comparative cohort study from BAFTA trial

BMJ ◽

10.1136/bmj.d3653 ◽

2011 ◽

Vol 342 (jun23 1) ◽

pp. d3653-d3653 ◽

Cited By ~ 32

Author(s):

F. D. R. Hobbs ◽

A. K. Roalfe ◽

G. Y. H. Lip ◽

K. Fletcher ◽

D. A. Fitzmaurice ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cohort Study ◽

Older People ◽

Stroke Risk ◽

Risk Scores ◽

Comparative Cohort Study

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Lack of Sex Disparity in Oral Anticoagulation in Atrial Fibrillation Patients Presenting with Ischemic Stroke in a Rural Population

Journal of Clinical Medicine ◽

10.3390/jcm10204670 ◽

2021 ◽

Vol 10 (20) ◽

pp. 4670

Author(s):

Eric Koza ◽

Johan Diaz ◽

Durgesh Chaudhary ◽

Shima Shahjouei ◽

Jiang Li ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Oral Anticoagulants ◽

Age Groups ◽

Age Group ◽

Stroke Patients ◽

Time Period ◽

Sex Disparities ◽

Male Sex ◽

Sex Disparity

Various studies on oral anticoagulants (OAC) use among atrial fibrillation (AF) patients have shown high rates of undertreatment and the presence of sex disparity. This study used the ‘Geisinger Neuroscience Ischemic Stroke’ (GNSIS) database to examine sex differences in OAC treatment among ischemic stroke patients with the pre-event diagnosis of AF in rural Pennsylvania between 2004 and 2019. We examined sex disparities in OAC undertreatment and associated risks based on age group and ischemic stroke year. A total of 1062 patients were included in the study and 1015 patients (96%) had CHA2DS2-VASc score ≥ 2, of which 549 (54.1%) were women. Undertreatment rates were not statistically significant between men and women in the overall cohort (50.0% vs. 54.5%, p = 0.18), and male sex was not found to be a significant factor in undertreatment (OR 0.82, 95% CI 0.62–1.09, p = 0.17). The result persisted even when patients were divided into four age groups and two groups based on the study time period. The undertreatment rates in both sex groups remained consistent following the introduction of novel oral anticoagulants. In conclusion, there was no evidence of sex disparity with respect to OAC treatment, even after stratifying the cohort by age and ischemic stroke year.

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A Cohort Study of the Effectiveness of Influenza Vaccine in Older People, Performed Using the United Kingdom General Practice Research Database

The Journal of Infectious Diseases ◽

10.1086/421274 ◽

2004 ◽

Vol 190 (1) ◽

pp. 1-10 ◽

Cited By ~ 102

Author(s):

Punam Mangtani ◽

Phillippa Cumberland ◽

Cathy R. Hodgson ◽

Jennifer A. Roberts ◽

Felicity T. Cutts ◽

...

Keyword(s):

General Practice ◽

Cohort Study ◽

United Kingdom ◽

Influenza Vaccine ◽

Older People ◽

General Practice Research Database ◽

Practice Research ◽

Research Database ◽

The United Kingdom

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Association between body mass index and the risk of atrial fibrillation and ischemic stroke according to age: a nationwide population-based cohort study

European Heart Journal ◽

10.1093/eurheartj/ehab724.2411 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

H J Ahn ◽

S R Lee ◽

E K Choi ◽

K D Han ◽

S I Kwon ◽

...

Keyword(s):

Atrial Fibrillation ◽

Body Mass Index ◽

Cohort Study ◽

Ischemic Stroke ◽

Body Mass ◽

Age Groups ◽

The Elderly ◽

Population Based ◽

Age Group ◽

Increased Risk

Abstract Background Atrial fibrillation (AF) and ischemic stroke (IS) are two significant cardiovascular diseases that confer an enormous healthcare burden. A limited study comprehensively evaluated the association between full ranges of body mass index (BMI), including underweight, and AF or IS risks, especially in the different age subgroups. Purpose We investigated the association between BMI and AF and IS incidence according to the Korean population's age groups. Methods This was a nationwide population-based cohort study using data from the Korea National Health Insurance Service, including 9 194 477 healthy adults who underwent a medical examination in 2009. We stratified the study population into three age subgroups: age 20–39 (young, 33.1%), age 40–64 (middle-aged, 56.3%), and age over 65 years (elderly, 10.6%). In each age group, the individuals were categorized based on BMI (kg/m2) into underweight (<18.5), normal (18.5 to <23), overweight (23 to <25), obese I (25 to <30), and obese II (≥30). The first occurrences of AF and IS were followed up until December 31, 2018. According to BMI in each age group, the risks of AF and IS were analyzed by Cox proportional hazards regression with 95% confidence intervals (CI) by adjusting age, sex, lifestyle behaviors, and comorbidities. Results Overall, both underweight and higher BMI were associated with an increased risk of AF and stroke across all age groups. The increased risk of AF for patients with obese II was slightly accentuated compared to patients with normal BMI in the young population than elderly population (hazard ratio [HR] 1.78, 95% CI 1.63–1.94 for age 20–39 years; HR 1.55, 95% CI 1.48–1.61 for age ≥65 years, respectively). For underweight individuals, however, the increased risk of AF became more prominent in the elderly: HR and 95% CI was 1.12 (1.07–1.17) in the age over 65 years old, and 1.05 (0.94–1.16) in the age 20–39. Regarding IS, the young group presented a considerable increment in the magnitude of HRs in both underweight and higher BMI groups. However, the association between the BMI and stroke risk became attenuated in the elderly: HRs and 95% CI in underweight and obese II individuals were 1.10 (0.93–1.30) and 2.223 (1.99–2.49) in the age 20–39 group, whereas 0.97 (0.93–1.01) and 1.03 (0.98–1.08) in the age over 65 years old. Conclusions Underweight as well as obesity was associated with increased risks of AF and IS in the general population. In both AF and IS, the gradient of risks according to BMI was apparent at young ages; thus, maintaining normal body weight should be warranted in early life. An interplay of several factors other than BMI may contribute to ischemic stroke in the old ages, requiring integrated risk management in older patients. FUNDunding Acknowledgement Type of funding sources: None.

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Ischemic stroke in low risk patients with atrial fibrillation: a nationwide, registry-based cohort study

European Heart Journal ◽

10.1093/eurheartj/ehab724.0439 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

Z Mandalenakis ◽

E Spanos ◽

T.V.S Sandstrom ◽

A.R Rosengren ◽

P.O.H Hansson

Keyword(s):

Atrial Fibrillation ◽

Cohort Study ◽

Ischemic Stroke ◽

Cardiovascular Risk ◽

Cox Regression ◽

Age Groups ◽

Good Evidence ◽

Aged Patients ◽

Cardiovascular Comorbidity ◽

Risk Patients

Abstract Background Despite the good evidence on the prevention of ischemic stroke in high risk patients with atrial fibrillation (AF), the knowledge in AF patients without any cardiovascular risk factors is still limited and the treatment has been highly questioned. Methods We linked data from Swedish health registers to identify all patients with AF but without any previous cardiovascular comorbidity. The risk of ischemic stroke was investigated by using Cox regression models and patients with AF compared with two controls without AF, matched for age and sex. Results Altogether, 229,613 patients with AF and 457,332 matched controls without AF were included in the study; 44.4% of the population were women. Both the 1-year and the 5-year risk to develop ischemic stroke was higher in patients with AF compared to their matched controls without AF, hazard ratio (HR) of 3.7 (95%, confidence interval (CI) 3.5–3.8) and 2.5 (95%, CI 2.5–2.6) respectively. According to the age groups, patients with age of 35 to 49 years had the highest risk to develop ischemic stroke within the first year after AF diagnosis, HR 8.3 (95%, CI 4.0–17.1). Women with AF had 4.4 times higher risk to develop ischemic stroke (HR 4.4, CI 4.2–4.7) compared to matched women without AF. Conclusions In this large, register-based, nationwide cohort study, we found that the 1-risk and 5-year risk to develop ischemic stroke was significantly higher in patients with AF but without any cardiovascular risk factor for stroke, compared to matched controls without AF. Women and middle-aged patients with AF carried the highest risk to develop ischemic stroke indicating the need of further research on risk stratification despite traditional factors. FUNDunding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): The Swedish state and The Swedish Research Council

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