Thromboprophylaxis of elderly patients with AF in the UK: an analysis using the General Practice Research Database (GPRD) 2000-2009

Abstract

ObjectiveTo assess use of thromboprophylaxis in UK general practise among patients with atrial fibrillation (AF); to investigate whether elderly patients are less likely to receive anticoagulation therapy than younger patients.DesignRetrospective cohort studySettingUK General Practice Research Database (GPRD)PatientsAged ≥60 years with a new diagnosis of AF (2000–2009).InterventionsNone.Main outcome measuresThe main outcome measure was initiation of warfarin in the first year following diagnosis. Patients were categorised by stroke risk (CHADS2 score) and bleeding risk (HAS-BLED score).Results81 381 patients were identified (21% aged 60–69 years, 37% aged 70–79 years, 42% aged 80+ years). Patients aged 80+ years were significantly less likely to be initiated on warfarin than younger patients, adjusted for gender, practice and comorbidities; 32% of patients aged 80+ years received warfarin compared with 57% aged 60–69 years (p<0.0001), and 55% aged 70–79 years (p<0.0001). For all strata of CHADS2/HASBLED scores, patients aged 80+ years were significantly less likely to be treated with warfarin than younger patients. Logistic regression showed that female sex, low Basal Metabolic Index (BMI), age over 80 years, increasing HAS-BLED score and dementia were independently associated with reduced use of warfarin. Stroke/Transient Ischaemic Attack (TIA), hypertension, heart failure and left ventricular systolic dysfunction were associated with increased use. Patients with HAS-BLED>CHADS2 were less likely to be initiated on warfarin. Higher CHADS2 scores were associated with increased anticoagulation use.ConclusionsAnticoagulation is being under-used in patients with AF aged 80+ years, even after taking into account increased bleeding risk in this age group.

Joint use of cardio-embolic and bleeding risk scores in elderly patients with atrial fibrillation

“…More interesting, the distribution of the percentages of patients treated with VKAs across the cells defined by the scores (Table 3) and the results of the logistic analyses showed that the patient's bleeding risk, but not the cardio-embolic risk alone, predicted the therapeutic choice. These findings on the relationship between the bleeding score and VKA prescription are consistent with those of the UK cohort [5]. In the literature, evidence on the relationship between cardio-embolic scores and VKA prescription in real settings is not uniform [5,23,24].…”

“…There was also a high representation of the high risk category for bleeding among REPOSI patients, higher than in the UK cohort [5]. As for the cardio-embolic scores, a reclassification effect with HAS-BLED was observed compared to HEMORR 2 HAGES.…”

“…Indeed, none of the REPOSI patients was at low HAS-BLED risk (because of age, none had a 0 score), and in 40% of them HAS-BLED classified patients into a higher risk category than HEMORR 2 HAGES. This effect was attenuated provided that a HAS-BLED score of 1 was included in the low risk category together with score 0 (as done in other studies [5,18]), yet only 11% of patients had a HAS-BLED score of 1. In fact, HAS-BLED was developed in order to provide a therapeutic guideline easier to memorize and includes more practicable risk factors than HEMORR 2 HAGES [14].…”

“…The cardio-embolic risk stratification of REPOSI patients resembled that recently described in an elderly cohort from the UK General Practice Research Database (GPRD) [5]. However, the REPOSI population had a higher representation of patients at intermediate-high CHADS 2 score, presumably because of a higher mean age and different selection criteria (patients at the time of hospital admission, with a likely higher rate of morbidity than those referred to general practitioners).…”

“…The underuse of vitamin K antagonists (VKAs) among elderly patients with atrial fibrillation (AF) has been confirmed in different settings [1][2][3][4][5][6]. Indeed, the CHA 2 DS 2 -VASc [6,7], that assigns 2 points (and not 1 as CHADS 2 [8]) to age ≥ 75 years, and 1 point to age ≥ 65 years would qualify all patients older than 75 years as candidates for long term anticoagulation, and all patients older than multimorbidity) currently rely upon a joint assessment of both cardioembolic and bleeding risks.…”