Direct oral anticoagulants in elderly patients with atrial fibrillation: a decade-long nationwide retrospective cohort study.

OBJECTIVE: To examine oral anticoagulant (OAC) prescription patterns and clinical outcomes, among elderly patients with atrial fibrillation (AF) during the era of widespread direct oral anticoagulant (DOAC) use. DESIGN: A retrospective cohort study. SETTING: This study used nationwide electronic health records from multiple centres across Israel. PARTICIPANTS: Patients with incident AF aged ≥75 years who were diagnosed between 1 January 2010 and 1 January 2020. OUTCOME MEASURES: Incidence of stroke, intracranial haemorrhage (ICH) and gastrointestinal bleeding (GIB) were estimated as the number of events per 100 person-years. Inverse probability weighting was used to estimate adjusted risk ratios for stroke, ICH, GIB and all-cause mortality. RESULTS: 45 820 patients were included. The median age was 83 (IQR, 79-83), including 26 590 females (58%); 15 019 received DOAC, 7114 used warfarin and 23 687 were OAC non-users. Overall initial OAC prescription rates increased from 31% in 2010 (100% warfarin) to 66% (98% DOAC) in 2019. Compared with OAC non-users, DOAC-treated patients had decreased risk of stroke (adjusted risk ratio (aRR) 0.71, 95% CI 0.64 to 0.79) and GIB (aRR 0.81, CI 0.74 to 0.90), but similar ICH risk (aRR 0.98, CI 0.84 to 1.16). Warfarin-treated patients had similar risk of stroke (aRR 1.1, CI 0.99 to 1.24), increased risk of ICH (aRR 1.32, CI 1.10 to 1.57) and GIB (aRR 1.13, CI 1.02 to 1.26). Both DOAC (aRR 0.83, CI 0.81 to 0.85) and warfarin (aRR 0.93, CI 0.90 to 0.95) groups had lower mortality risk than OAC non-users. CONCLUSIONS: Among elderly patients with AF, DOAC use increased over time and was associated with favourable clinical outcomes.