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

## TL;DR

This study shows that stroke-prevention medications for patients with atrial fibrillation and COPD have shifted from warfarin to NOACs over a decade, with fewer strokes and bleeds.

## Contribution

The study provides new insights into medication trends and outcomes for stroke prevention in AF patients with COPD using nationwide real-world data.

## Key findings

- NOAC use increased from 15.4% to 65.4% between 2013 and 2022, while warfarin use decreased.
- Ischemic stroke and major bleeding incidence rates declined significantly over the study period.
- COPD exacerbation history did not influence stroke-prevention medication prescription patterns.

## Abstract

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.

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.

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.

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.