Long-term real-world trends and appropriateness of oral anticoagulants therapy in non-valvular atrial fibrillation: A retrospective secondary analysis of the China Atrial Fibrillation Registry (2011–2022)

Objectives: Real-world data on oral anticoagulant (OAC) use patterns and dosing appropriateness in patients with non-valvular atrial fibrillation remain limited in China. This study aims to characterize trends in OAC prescribing and assess the dosing appropriateness of direct oral anticoagulants (DOAC) in non-valvular atrial fibrillation. Methods: This is a retrospective secondary analysis of the prospective China Atrial Fibrillation (China-AF) Registry (ChiCTR-OCH-13003729, registered on October 22, 2013), using data from patients with non-valvular atrial fibrillation who were discharged on OAC between 2011 and 2022. Real-world trends in warfarin vs. DOAC use and dosing appropriateness were evaluated. Predictors of inappropriate DOAC dosing were identified. Results: Among the included patients, 10,205 received warfarin and 15,084 received DOAC. The propotion of DOAC prescription increased from 0% in 2011 to 98% after 2020, whereas warfarin use declined from 99.74% to 1.99%. The shift accelerated after 2017, coinciding with the inclusion of dabigatran and rivaroxaban into the National Reimbursement Drug List. DOAC were less frequently prescribed to high-risk patients, including those with higher CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age (≥75 years earns 2 points, 65-74 years earns 1 point), diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism (2 points), vascular disease (e.g., prior myocardial infarction, peripheral artery disease), and female sex category) and HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>65 years), Drugs/alcohol use) scores, older age, lower creatinine clearance (all P for trend < 0.05). Inappropriate dosing was more prevalent in these higher-risk groups ( P for trend < 0.001). Older age was independently associated with inappropriate dosing (per 10 years, OR=1.39, 95% CI: 1.29-1.51, P < 0.001). In contrast, male (OR=0.77, 95% CI: 0.65-0.91, P = 0.002), prescriptions post-2017 (OR=0.12, 95% CI: 0.07-0.20, P < 0.001), persistent AF (OR=0.78, 95% CI 0.67-0.92, P = 0.002) and dabigatran use (OR=0.020, 95% CI: 0.020-0.028, P < 0.001) were associated with lower odds of inappropriate dosing. Conclusions: From 2011 to 2022, OAC prescribing in China shifted dramatically from warfarin to DOAC, with more rapid DOAC adoption after the 2017 National Reimbursement Drug List update. Although DOAC dosing appropriateness improved over time, inappropriate dosing remained common in higher-risk patients, particularly older adults.