Abstract
Among atrial fibrillation (AF) patients, Danish nationwide registries (2011–2015) were used to examine temporal trends of initiation patterns of oral anticoagulation (OAC) treatment according to age. Overall, 43,299 AF patients initiating vitamin K antagonists (VKA) (42%), dabigatran (29%), rivaroxaban (13%), or apixaban (16%) were included with mean age (SD) 72.1 (11.3), 71.5 (11.0), 74.3 (11.1), and 75.3 (11.1) years, respectively. Patients aged ≥85 years comprised 15%. Trend tests showed increase in patients ≥85 years initiating OAC (p < 0.0001). VKA usage decreased from 92% to 24% (p < 0.0001). This decrease was independent of age. Dabigatran was the most common non-VKA OAC (NOAC) (40% users), but usage decreased from 2014 until study end (6%) (p < 0.0001). Apixaban was the most used OAC at study end (41%), in particular among those ≥85 years (44%). Compared with patients aged <65 years, the odds ratios associated with initiating VKA, dabigatran, rivaroxaban, or apixaban for patients aged ≥85 years were 0.81 (95% CI 0.75–0.86), 0.65 (95% CI 0.60–0.70), 1.52 (95% CI 1.38–1.67), and 2.09 (95% CI 1.89–2.30), respectively. In conclusion, substantial increase in NOAC usage has occurred. Increasing age was associated with upstart of rivaroxaban or apixaban with reference to age <65 within the specific agent.
Highlights
Vitamin K antagonists (VKA) have for decades been the only oral anticoagulation (OAC) agent available for stroke prevention in patients with atrial fibrillation (AF), but recently, the landscape for stroke prevention has rapidly changed by the introduction of the non-VKA oral anticoagulants (NOACs)[1,2,3]
Our principal findings were: (i) the absolute number of patients initiating OAC has increased among patients aged
The suboptimal OAC treatment of elderly patients has been subject to increased focus in recent years as elderly patients are at particular high risk of stroke[9,13,14], and prior studies have shown that OAC provides a net clinical benefit among elderly AF patients[14]
Summary
Vitamin K antagonists (VKA) have for decades been the only oral anticoagulation (OAC) agent available for stroke prevention in patients with atrial fibrillation (AF), but recently, the landscape for stroke prevention has rapidly changed by the introduction of the non-VKA oral anticoagulants (NOACs)[1,2,3]. In Denmark, dabigatran was the first NOAC approved for stroke prevention (22 August 2011), followed by rivaroxaban (6 February 2012) and apixaban (10 December 2012). Recent European consensus guidelines from 2015 recommend oral FXa inhibitors (rivaroxaban, apixaban, or edoxaban) over VKAs in the elderly if CrCl >1 5 ML/min, and in Denmark, we follow the European guidelines, but with the modification that VKA is recommended if time in therapeutic range ≥70%8. The main objective of this study was to examine temporal trends between 2011 and 2015 of the initiation patterns of NOACs from a nationwide cohort of AF patients in Denmark, and to examine these temporal trends in relation to age
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