Increasing use of the non–vitamin K antagonist oral anticoagulants (NOACs) has driven an overall rise in the prescription of oral anticoagulant drugs in patients with atrial fibrillation, according to a late–breaking analysis in more than 11 000 patients presented at ESC Congress.

The EURObservational Research Programme Atrial Fibrillation (EORP–AF) Long–Term General Registry evaluated the use of oral anticoagulants in patients with atrial fibrillation in real world clinical practice across Europe. This registry, organised by the European Society of Cardiology, follows the EORP–AF Pilot Registry which enrolled around 3 000 patients and strongly contributed to knowledge in the field.

In the EORP–AF Long–Term General Registry presented factors influencing the use of vitamin K antagonists (VKA) and the newer NOACs were analysed. This prospective, observational registry included 11 096 patients with atrial fibrillation from 27 European countries who were enrolled between October 2013 and September 2016 from inpatient and outpatient cardiology clinics.

An oral anticoagulant drug was used in most patients (85%) with atrial fibrillation. Of those on oral anticoagulation, 59% received a VKA and 41% were treated with a NOAC. Prof Giuseppe Boriani, chairman of the EORP–AF Long–Term General Registry and full professor of cardiology at the University of Modena and Reggio Emilia, Italy, said: “The overall use of oral anticoagulants in atrial fibrillation has increased by around 5% since the previous survey which is good news since this results in protection of our patients from ischaemic stroke. This rise in oral anticoagulant use was largely driven by the increase in uptake of NOACs.”

In the four years since the last survey, NOAC use increased from 10% to 41% of those on oral anticoagulants. “This probably reflects the fact that NOACs have become more available throughout Europe,” said Prof Boriani.

Less clinically complex patients were more likely to be treated with NOACs than VKAs. Patients were less likely to receive NOACs if they had coronary artery disease, received pharmacological cardioversion, or had heart failure – despite evidence that these drugs can be safely used.

ESC guidelines recommend NOACs over VKAs, but there was a large variability in NOAC use across European regions. Patients prescribed oral anticoagulants were more likely to receive NOACs if they lived in Northern and Western Europe and VKAs if they lived in Eastern and Southern Europe.

Nearly two–thirds (63%) of patients at low thromboembolic risk received oral anticoagulants. “According to ESC guidelines, these patients should not be receiving oral anticoagulants unless a cardioversion is planned, so better attention and adherence to recommendations is needed,” said Prof Boriani. “Conversely, there was a tendency to underuse oral anticoagulants in patients with both a high risk of bleeding and a high risk of stroke.”

Patients were more likely to receive oral anticoagulant therapy if they had characteristics or conditions that increase thromboembolic risk. These included age, hypertension, previous thromboembolic events, and symptoms due to their atrial fibrillation. Patients were more likely to not receive oral anticoagulant therapy if they had conditions that increase the risk of bleeding, such as chronic kidney disease and previous haemorrhagic events.

Prof Boriani said: “This is the largest and most up–to–date snapshot of oral anticoagulant use in patients with atrial fibrillation across Europe that is organised by a scientific society rather than industry.”