Predictors of oral anticoagulant non-prescription in patients with atrial fibrillation and elevated stroke risk

Am Heart J. 2018 Jun;200:24-31. doi: 10.1016/j.ahj.2018.03.003. Epub 2018 Mar 10.


Background: Many patients with atrial fibrillation (AF) and elevated stroke risk are not prescribed oral anticoagulation (OAC) despite evidence of benefit. Identification of factors associated with OAC non-prescription could lead to improvements in care.

Methods and results: Using NCDR PINNACLE, a United States-based ambulatory cardiology registry, we examined factors associated with OAC non-prescription in patients with non-valvular AF at elevated stroke risk (CHA2DS2-VASc ≥2) between January 5, 2008 and December 31, 2014. Among 674,841 patients, 57% were treated with OAC (67% of whom were treated with warfarin). OAC prescription varied widely (28%-75%) across preselected strata of age, stroke risk (CHA2DS2-VASc), and bleeding risk (HAS-BLED), generally indicating that older patients at high stroke and low bleeding risk are commonly treated with OAC. Other factors associated with OAC non-prescription included reversible AF etiology; female sex; liver, renal, or vascular disease; and physician versus non-physician provider. Antiplatelet use was common (57%) and associated with the greatest risk of OAC non-prescription (odds ratio [OR] 4.44, 95% confidence interval [CI] 4.39-4.49).

Conclusions: In this registry of AF patients, older patients at elevated stroke and low bleeding risk were commonly treated with OAC. However, a variety of factors were associated with OAC non-prescription. Specifically, antiplatelet use was prevalent and associated with the highest likelihood of OAC non-prescription. Future studies are warranted to understand provider and patient rationale that may underlie observed associations with OAC non-prescription.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anticoagulants* / classification
  • Anticoagulants* / therapeutic use
  • Atrial Fibrillation* / complications
  • Atrial Fibrillation* / drug therapy
  • Atrial Fibrillation* / epidemiology
  • Female
  • Health Services Misuse* / prevention & control
  • Health Services Misuse* / statistics & numerical data
  • Hemorrhage* / chemically induced
  • Hemorrhage* / prevention & control
  • Humans
  • Male
  • Middle Aged
  • Platelet Aggregation Inhibitors / therapeutic use
  • Practice Patterns, Physicians' / standards
  • Quality Improvement
  • Registries / statistics & numerical data
  • Risk Assessment
  • Risk Factors
  • Stroke* / etiology
  • Stroke* / prevention & control
  • United States / epidemiology


  • Anticoagulants
  • Platelet Aggregation Inhibitors