Evaluating the effect of inequalities in oral anti-coagulant prescribing on outcomes in people with atrial fibrillation

Mulholland, R.J. , Manca, F., Ciminata, G., Quinn, T.J. , Trotter, R., Pollock, K.G., Lister, S. and Geue, C. (2024) Evaluating the effect of inequalities in oral anti-coagulant prescribing on outcomes in people with atrial fibrillation. European Heart Journal Open, (doi: 10.1093/ehjopen/oeae016) (Accepted for Publication)

Abstract

Background Whilst anti-coagulation is typically recommended for thromboprophylaxis in atrial fibrillation (AF), it is often never prescribed, or prematurely discontinued. The aim of this study was to evaluate the effect of inequalities in anti-coagulant prescribing by assessing stroke/systemic embolism (SSE) and bleeding risk in people with AF who continue anticoagulation compared with those who stop transiently, permanently, or never start. Methods This retrospective cohort study utilised linked Scottish healthcare data to identify adults diagnosed with AF between January 2010 and April 2016, with a CHA2DS2-VASC score of ≥2. They were sub-categorised based on anti-coagulant exposure: never started, continuous, discontinuous, and cessation. Inverse probability of treatment weighting-adjusted Cox regression and competing-risks regression were utilised to compare SSE and bleeding risks between cohorts during five year follow-up. Results Of an overall cohort of 47,427 people, 26,277 (55.41%) were never anti-coagulated, 7,934 (16.72%) received continuous anti-coagulation, 9,107 (19.2%) temporarily discontinued and 4,109 (8.66%) permanently discontinued. Lower socio-economic status, elevated frailty score, and age ≥75 were associated with a reduced likelihood of initiation and continuation of anti-coagulation. SSE risk was significantly greater in those with discontinuous anti-coagulation, compared to continuous (SHR: 2.65; 2.39-2.94). In the context of a major bleeding event, there was no significant difference in bleeding risk between the cessation and continuous cohorts (SHR 0.94; 0.42-2.14). Conclusion Our data suggest significant inequalities in anti-coagulation prescribing, with substantial opportunity to improve initiation and continuation. Decision-making should be patient-centered and must recognise that discontinuation or cessation is associated with considerable thromboembolic risk not offset by mitigated bleeding risk.

• Item Type: Articles
• Additional Information: This study was sponsored by Pfizer and Bristol Myers Squibb.
• Status: Accepted for Publication
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Quinn, Professor Terry and Ciminata, Dr Giorgio and Geue, Dr Claudia and Manca, Mr Francesco and Mulholland, Dr Ryan

Creator Roles

Mulholland, R.: Data curation, Formal analysis, Writing – original draft
Manca, F.: Data curation, Writing – review and editing
Ciminata, G.: Data curation, Writing – review and editing
Quinn, T.: Conceptualization, Methodology, Writing – review and editing
Geue, C.: Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review and editing

• Authors: Mulholland, R.J., Manca, F., Ciminata, G., Quinn, T.J., Trotter, R., Pollock, K.G., Lister, S., and Geue, C.
• College/School: College of Medical Veterinary and Life Sciences > School of Cardiovascular & Metabolic Health; College of Medical Veterinary and Life Sciences > School of Health & Wellbeing > Health Economics and Health Technology Assessment
• Journal Name: European Heart Journal Open
• Publisher: Oxford University Press
• ISSN: 2752-4191
• ISSN (Online): 2752-4191
• Published Online: 05 March 2024