The use of anticoagulants in the management of atrial fibrillation among general practices in England

Abstract

ObjectivesTo investigate the use of oral anticoagulants (AC) and antiplatelet agents (AP) in the management of atrial fibrillation (AF) among patients in primary care in England.DesignEpidemiological study.Setting1857 general practices in England representing a practice population of 13.1 million registered patients.Patients231 833 patients with a history of AF.Main outcome measuresThe primary outcome was AC and AP use by CHADS2 score and age groups <30 years, 30–49 years, 50–64 years, 65–79 years and >79 years.Results231 833 patients with a history of AF were identified, giving a prevalence among uploading practices of 1.76%. Prevalence of AF varied markedly between practices, related to differing practice age profiles. The total number of patients with AF in a practice was strongly predicted by the number of patients aged 65 years and over in the practice. 57.0% of the AF population had a CHADS2 score ≥2 and 83.7%≥1. 114 212 (49.3%) patients received AC therapy. AC uptake increased with increasing CHADS2 score up to a score of 3, but thereafter reached a plateau. Among 132 099 patients with a CHADS2 score ≥2, 72 211 (54.7%) received an AC, 14 987(11.3%) were recorded as having a contraindication or having declined AC therapy, leaving 44 901 (34.0%) not on AC therapy and without a recorded contraindication or recorded refusal. Among patients not prescribed an AC, 79.9% were prescribed an AP. The use of AC declined in the elderly (for CHADS2≥2, 47.4% of patients ≥80 years, compared with 64.5% for patients aged <80 years, p<0.001). By contrast, AP uptake was more prevalent among elderly patients.ConclusionsOver one-third of patients with AF and known risk factors who are eligible for AC do not receive them. There is a high use of AP among patients not receiving AC. Uptake of AC is particularly poor among patients aged 80 years and over.

Untreated atrial fibrillation in the United Kingdom: Understanding the barriers and treatment options

“…Among high-risk patients with CHADS 2 P2, the prescription of anticoagulation was 47.4% for patients aged 80 years and over compared with 64.5% for younger patients. Overall, this study suggested that less than half (49.3%) of patients with a history of AF received an anticoagulant and that anticoagulant uptake increases through CHADS 2 score 0-3 and thereafter reaches a plateau [16]. These results are similar to those of another recent study [12] and represent an improvement compared to what had previously been described [32].…”

“…A more recent study in England revealed that the overall prevalence of AF among practices uploading data from 2009 to 2012 was 1.76% [16]. The prevalence of AF roughly doubles with each advancing decade of age, from 0.5% at age 50-59 years to almost 9% at age 80-90 years [17].…”

“…Potential barriers to appropriate treatment include inadequate risk stratification, the (advanced) age of the patient, perceived bleeding risk and risk of falling, the pitfalls of warfarin, such as the requirements for regular monitoring, frequent dosage adjustments, dietary restrictions and susceptibility to drug interactions, the high cost of the new oral anticoagulants, the difficulty in identifying asymptomatic AF patients, and the lack of appropriate education. Based on a number needed to treat from the Birmingham Atrial Fibrillation Treatment of the Aged (BAFTA) study of 50 to prevent one thromboembolic event or intracranial haemorrhage [38], and on observations from the study by Cowen et al [16], it is estimated that 24 in excess of 3000 strokes could potentially be prevented annually if these individuals were commenced on anticoagulation in preference to antiplatelet drugs [16].…”

“…The Guidance on Risk Assessment and Stroke Prevention in Atrial Fibrillation (GRASP-AF) tool searches general practice clinical information to identify patients with history of AF, reviews their risk profiles, and provides insights into the prevalence and management of AF in England [16]. According to GRASP-AF, the proportion of patients with AF who were prescribed anticoagulants and antiplatelet agents was 49.3% and 42.5%, respectively, with 6.9% of patients being prescribed both agents.…”

“…The rate of incident hospitalization for AF was 1.9 cases/1000 person-years. Incidence of AF in the UK is estimated at up to 0.3% [7,[15][16][17][18][19].…”