OAC use among older AFib patients is on the rise

More and more Medicare patients with atrial fibrillation (AFib) are taking oral anticoagulants (OACs) to prevent strokes, according to a new analysis published in JAMA Network Open.[1] However, researchers noted, there is still considerable room for improvement; too many patients are still missing out on this effective treatment option.

The prevalence of AFib increases exponentially with advancing age, and cardioembolic stroke resulting from AFib accounts for 1 in every 3 ischemic strokes in adults older than 65 years,” wrote first author Darae Ko, MD, MSc, an assistant professor of medicine at Boston University School of Medicine, and colleagues. “AFib increases the risk of cardioembolic stroke 5-fold without anticoagulation, and AFib-related strokes are more often fatal and cause greater disability compared with non-AFib strokes. Warfarin reduces the risk of ischemic stroke and systemic embolism … but only approximately 55% of older adults with AFib and guideline eligibility for an OAC were prescribed warfarin in 2010.”

Did the introduction of direct OACs (DOACs) in 2010 improve OAC initiation among this patient population? To find out, Ko et al. examined data from more than 380,000 Medicare beneficiaries with new diagnoses of AFib who were treated from 2010 to 2020.

Overall, the group found, the rate of OAC initiation within 12 months of a new AFib diagnosis increased from 20.2% in 2010 to 32.9% in 2020. Nonadherence also improved, dropping from 52.2% in 2010 to 39% in 2020.

DOAC initiation, as one might expect, was low in 2010—the newly introduced treatment option was seen in just 1.1% of eligible patients. By 2020, however, 30.9% of patients were taking DOACs to reduce their risk of stroke. Also, warfarin initiation plummeted during that same window of time, going from 19.1% in 2010 to 2% in 2020.

Older age, dementia, frailty and anemia were all identified as patient factors associated with a reduced likelihood of taking OACs—DOACs or otherwise—among Medicare patients with a new AFib diagnosis.

The study’s authors also noted that the risk of a bleeding event has always been a significant reason more patients do not take OACs. Even after DOACs were introduced, this appears to still be an issue that is limiting OAC initiation.

“Additional strategies are needed to improve OAC utilization in patients at high bleeding and stroke risks and to develop alternative strategies for stroke prophylaxis in patients with untenable bleeding risk,” the group wrote.

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