What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Atrial Fibrillation (n=224506). Intervention: Time period (2018 vs 2008) vs. 2008. Primary outcome: Proportion of patients prescribed anticoagulants.

July 5, 2021Open Access

Trends in the pharmacological management of atrial fibrillation in UK general practice 2008–2018

Key Result

Between 2008 and 2018, the proportion of patients with atrial fibrillation prescribed anticoagulants increased from 45.3% to 71.1%, driven by increased prescription of non-vitamin K antagonist oral anticoagulants.

Study Design

Type

Cross-Sectional (n=224,506)

Multicenter

Yes

Structured PICO

Population

224,506 adults with atrial fibrillation and eGFR >30mL/min from UK primary care practices, assessed in repeated cross-sectional analyses between 2008 and 2018.

Exposure

Pharmacological management of AF including anticoagulants (warfarin, NOACs), rate control drugs (beta blockers, calcium channel blockers, digoxin), and rhythm control drugs (flecainide, amiodarone, dronedarone, propafenone).

Outcome

Proportion of patients with AF prescribed anticoagulants, rhythm and rate control drugs in the whole cohort, those at high risk of stroke, and those with coexisting heart failure.

Over a decade, UK primary care prescribing for AF has increasingly aligned with guidelines, marked by a significant rise in anticoagulant use (driven by NOACs) and a decline in rhythm control therapies.

Main Result

Absolute Event Rate: 71.1% vs 45.3%

Limitations

Medications prescribed in secondary care may not be captured.
"Pill in the pocket" prescriptions of rhythm control therapy may not have been captured within the 90 days prior to the census date.
Unable to capture when treatments were initiated.
Does not reflect persistence on treatment or adherence to medication.
Cannot assume all drugs were prescribed specifically for the management of AF.
Exclusion of patients with eGFR ≤30mL/min limits generalizability to patients without severe renal impairment.

Abstract

OBJECTIVE: The pharmacological management of atrial fibrillation (AF) comprises anticoagulation, for stroke prophylaxis, and rate or rhythm control drugs to alleviate symptoms and prevent heart failure. The aim of this study was to investigate trends in the proportion of patients with AF prescribed pharmacological therapies in the UK between 2008 and 2018. METHODS: Eleven sequential cross-sectional analyses were performed yearly from 2008 to 2018. Data were derived from an anonymised UK primary care database. Outcomes were the proportion of patients with AF prescribed anticoagulants, rhythm and rate control drugs in the whole cohort, those at high risk of stroke and those with coexisting heart failure. RESULTS: Between 2008 and 2018, the proportion of patients prescribed anticoagulants increased from 45.3% (95% CI 45.0% to 45.7%) to 71.1% (95% CI 70.7% to 71.5%) driven by increased prescription of non-vitamin K antagonist anticoagulants. The proportion of patients prescribed rate control drugs remained constant between 2008 and 2018 (69.3% (95% CI 68.9% to 69.6%) to 71.6% (95% CI 71.2% to 71.9%)). The proportion of patients prescribed rhythm control therapy by general practitioners (GPs) decreased from 9.5% (95% CI 9.3% to 9.7%) to 5.4% (95% CI 5.2% to 5.6%). CONCLUSIONS: There has been an increase in the proportion of patients with AF appropriately prescribed anticoagulants following National Institute for Health and Care Excellence and European Society of Cardiology guidelines, which correlates with improvements in mortality and stroke outcomes. Beta-blockers appear increasingly favoured over digoxin for rate control. There has been a steady decline in GP prescribing rates for rhythm control drugs, possibly related to concerns over efficacy and safety and increased availability of AF ablation.

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