Abstract
Background Anticoagulation therapy reduces stroke risk in patients with atrial fibrillation (AF), but it is often underused in older populations due to concerns about bleeding. This study aimed to compare the safety and effectiveness of anticoagulation during periods of exposure and non-exposure and across different anticoagulants in people with AF aged ≥75 years.
Methods Using UK primary care data from the Clinical Practice Research Datalink (2013–2017), a retrospective cohort study was conducted on patients newly prescribed oral anticoagulants (warfarin or direct oral anticoagulants). Exposure to anticoagulation was mapped using prescription data. Cox regression models were used to estimate adjusted HRs for stroke, bleeding, myocardial infarction, and death during periods of exposure and non-exposure and for different anticoagulants.
Results Among 20 167 patients (median age 81 years), non-exposure to anticoagulation was associated with higher risks of stroke (HR 3.07, 95% CI 2.39 to 3.93), myocardial infarction (HR 1.85, 95% CI 1.34 to 2.56) and death (HR 2.87, 95% CI 2.63 to 3.12) compared with exposure. Compared with warfarin, apixaban was associated with lower risks of non-major bleeding (HR 0.73, 95% CI 0.64 to 0.85), whereas rivaroxaban was associated with higher risks of major (HR 1.33, 95% CI 1.15 to 1.55) and non-major (HR 1.29, 95% CI 1.16 to 1.44) bleeding.
Conclusions Non-exposure to anticoagulation increases the risks of stroke, myocardial infarction and death in older patients with AF. Clinicians should carefully weigh the risks of discontinuing anticoagulation and provide shared decision-making support to patients, especially when considering deprescription.
Methods Using UK primary care data from the Clinical Practice Research Datalink (2013–2017), a retrospective cohort study was conducted on patients newly prescribed oral anticoagulants (warfarin or direct oral anticoagulants). Exposure to anticoagulation was mapped using prescription data. Cox regression models were used to estimate adjusted HRs for stroke, bleeding, myocardial infarction, and death during periods of exposure and non-exposure and for different anticoagulants.
Results Among 20 167 patients (median age 81 years), non-exposure to anticoagulation was associated with higher risks of stroke (HR 3.07, 95% CI 2.39 to 3.93), myocardial infarction (HR 1.85, 95% CI 1.34 to 2.56) and death (HR 2.87, 95% CI 2.63 to 3.12) compared with exposure. Compared with warfarin, apixaban was associated with lower risks of non-major bleeding (HR 0.73, 95% CI 0.64 to 0.85), whereas rivaroxaban was associated with higher risks of major (HR 1.33, 95% CI 1.15 to 1.55) and non-major (HR 1.29, 95% CI 1.16 to 1.44) bleeding.
Conclusions Non-exposure to anticoagulation increases the risks of stroke, myocardial infarction and death in older patients with AF. Clinicians should carefully weigh the risks of discontinuing anticoagulation and provide shared decision-making support to patients, especially when considering deprescription.
| Original language | English |
|---|---|
| Pages (from-to) | 565-574 |
| Number of pages | 10 |
| Journal | Heart |
| Volume | 111 |
| Issue number | 12 |
| Early online date | 17 Feb 2025 |
| DOIs | |
| Publication status | Published - 1 Jun 2025 |
Bibliographical note
Publisher Copyright:© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.
Data Availability Statement
Data may be obtained from a third party and are not publicly available. The data that support the findings of this study are available from the Clinical Practice Research Datalink, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. The Read code lists used to identify AF, comorbidities and concomitant medication are available on request from the corresponding author.Funding
This study was supported by a Research Training Fellowship awarded to the lead author from The Dunhill Medical Trust (grant number RTF109/0117). The funder had no role in the data collection, analysis, interpretation of data or writing the manuscript.
| Funders | Funder number |
|---|---|
| Dunhill Medical Trust | RTF109/0117 |
Keywords
- ANTICOAGULATION
- Atrial Fibrillation
- Clinical
- Epidemiology
- Pharmacology
- Stroke
ASJC Scopus subject areas
- Cardiology and Cardiovascular Medicine