Temporal trends in stroke-prevention medication use in patients with atrial fibrillation and chronic obstructive pulmonary disease

Abstract

Background: Patients with atrial fibrillation (AF) and concomitant chronic obstructive pulmonary disease (COPD) have been reported to exhibit a higher risk of stroke, particularly among those with a history of COPD exacerbations. However, the prescription patterns of stroke-prevention medications in this population remain unclear. This study aimed to characterize the temporal trends of stroke-prevention therapies among patients with COPD and AF, to describe concurrent trends in clinical outcomes, and to assess whether prescribing patterns differed by COPD exacerbation history.

Methods: Newly diagnosed AF and COPD patients were identified from Taiwan's National Health Insurance Research Database between 1 January 2013, and 31 December 2022. Prescription patterns of stroke-prevention medications within 1 year after AF diagnosis were examined. Stroke-prevention medications included warfarin, non-vitamin K antagonist oral anticoagulants (NOACs), and oral antiplatelet agents (OAPTs). The temporal changes of medication use and 1-year incidence rate of ischemic stroke and major bleeding across AF diagnosis years were analyzed.

Results: A total of 13,072 patients were included. From 2013 to 2022, use of any NOAC increased from 15.4% to 65.4% of patients, whereas warfarin use declined from 24.0% to 6.1% (both p < 0.0001). For patient-level prescription patterns, the proportion of patients receiving NOAC only increased from 2.6% in 2013 to 33.1% in 2022. Use of NOAC plus OAPT also rose steadily from 7.6% to 29.6%, becoming the second most common pattern after 2018. The overall treatment landscape shifted markedly from warfarin- or antiplatelet-based regimens to those predominantly centered on NOACs (p < 0.0001). Concurrent trends in ischemic stroke and major bleeding incidence rates both declined significantly over time (p = 0.0025 and p < 0.0001, respectively). The prescription pattern showed no statistically significant difference between patients with or without a COPD exacerbation history.

Conclusion: Nationwide real-world data demonstrated a dramatic shift over the past decade in stroke-prevention strategies among patients with coexisting COPD and AF, moving from warfarin- or OAPT-based therapy to predominantly NOAC-based therapy. Ischemic stroke and major bleeding were decreased over the calendar years. COPD exacerbation history did not alter stroke-prevention medication use, though this subgroup warrants attention due to elevated cardiovascular risks.

Keywords: atrial fibrillation; chronic obstructive pulmonary disease; prescription pattern; stroke prevention; temporal trend.