There are racial and socioeconomic inequalities in the prescribing of oral anticoagulants to reduce stroke risk in people with atrial fibrillation, according to a new study conducted in the UK and publishing June 7th in the open-access journal PLOS Medicine by Alyaa Ajabnoor of the University of Manchester, United Kingdom, and colleagues.
Atrial fibrillation (AF) is one of the most important risk factors for future stroke and the current treatment of choice is oral anticoagulants (OACs). However, studies have reported the frequent under-use of OACs in AF patients. Ajabnoor and colleagues used electronic health records from general physician practices in England, as reported in the UK Clinical Practice Research Datalink (CPRD) database, to estimate the incidence of non-valvular atrial fibrillation (NVAF) and trends in OAC prescribing.
The study found that the incidence rates of NVAF per 100,000 person-years increased from 20.8 (95% CI 20.4-21.1) in 2009 to 25.5 (95% CI 25.1-25.9) in 2019 and were markedly higher among males. Among NVAF patients eligible for anticoagulation, OAC prescribing rose by almost a quarter, from 59.8% (95% CI 59.0-60.6) in 2009 to 83.2% (95% CI 83.0-83.4) in 2019. Compared to white patients, patients from black (OR 0.78, 95% CI 0.65-0.94) and other ethnic minorities (OR 0.76, 95% CI 0.64-0.91) were less likely to receive OAC. Patients living in the most deprived areas were also less likely to receive OAC compared to those in the least deprived areas (OR0.85, 95% CI0.79-0.91). Associations were also seen between OAC prescriptions and clinical factors including dementia, liver disease, malignancy, and history of falls.
The study was limited by the fact that the data depended on accurate recording of conditions by health professionals, and there may have been additional confounding factors associated with the under-prescribing of OACs. However, the authors conclude that clinical and sociodemographic factors play a role in the under-prescribing 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," the authors say.
Our study reveals deep inequalities of care for atrial fibrillation patients."
Alyaa Ajabnoor, University of Manchester
Ajabnoor, A.M., et al. (2022) Incidence of nonvalvular atrial fibrillation and oral anticoagulant prescribing in England, 2009 to 2019: A cohort study. PLOS Medicine. doi.org/10.1371/journal.pmed.1004003.