The use of anticoagulants in the management of atrial fibrillation among general practices in England

Objectives To investigate the use of oral anticoagulants (AC) and antiplatelet agents (AP) in the management of atrial fibrillation (AF) among patients in primary care in England. Design Epidemiological study. Setting 1857 general practices in England representing a practice population of 13.1 million registered patients. Patients 231 833 patients with a history of AF. Main outcome measures The primary outcome was AC and AP use by CHADS(2) score and age groups <30 years, 30-49 years, 50-64 years, 65-79 years and >79 years. Results 231 833 patients with a history of AF were identified, giving a prevalence among uploading practices of 1.76%. Prevalence of AF varied markedly between practices, related to differing practice age profiles. The total number of patients with AF in a practice was strongly predicted by the number of patients aged 65 years and over in the practice. 57.0% of the AF population had a CHADS(2) score >= 2 and 83.7%>= 1. 114 212 (49.3%) patients received AC therapy. AC uptake increased with increasing CHADS(2) score up to a score of 3, but thereafter reached a plateau. Among 132 099 patients with a CHADS(2) score >= 2, 72 211 (54.7%) received an AC, 14 987(11.3%) were recorded as having a contraindication or having declined AC therapy, leaving 44 901 (34.0%) not on AC therapy and without a recorded contraindication or recorded refusal. Among patients not prescribed an AC, 79.9% were prescribed an AP. The use of AC declined in the elderly (for CHADS(2)>= 2, 47.4% of patients >= 80 years, compared with 64.5% for patients aged <80 years, p<0.001). By contrast, AP uptake was more prevalent among elderly patients. Conclusions Over one-third of patients with AF and known risk factors who are eligible for AC do not receive them. There is a high use of AP among patients not receiving AC. Uptake of AC is particularly poor among patients aged 80 years and over.