Temporal Trends in Anticoagulant Prescribing in Patients with Atrial Fibrillation According to Prior Ischemic Stroke or Transient Ischemic Attack: Insights from the CRAFT Registry.

Introduction and Objectives: Patients with atrial fibrillation (AF) and prior ischemic stroke or transient ischemic attack (TIA) are at high risk of recurrent thromboembolic events. Although direct oral anticoagulants (DOACs) have progressively replaced vitamin K antagonists (VKAs), it remains uncertain whether prior stroke/TIA influences anticoagulant prescribing or modifies temporal prescribing trends. Methods: This retrospective analysis included 3572 hospitalizations from the CRAFT registry between 2017 and April 2026. Hospitalization was the unit of analysis, and prior ischemic stroke/TIA status was determined at each admission. Anticoagulant prescribing was evaluated hierarchically as OAC versus no OAC, DOAC versus VKA, DOAC molecule selection, and, in exploratory analyses, within-molecule dose selection. Multivariable logistic and multinomial models included calendar year, age, sex, hypertension, diabetes mellitus, heart failure, AF type, and estimated glomerular filtration rate, with patient-level cluster-robust standard errors. Temporal trends and their interaction with prior stroke/TIA were assessed. Sensitivity analyses included categorical modeling of calendar year, exclusion of January-April 2026, and complete-case adjustment for atherosclerotic vascular disease. Benjamini-Hochberg FDR correction was applied to exploratory drug-specific comparisons. Results: Among 3572 hospitalizations, 437 (12.2%) involved patients with prior ischemic stroke/TIA. Prior stroke/TIA was not independently associated with OAC versus no OAC (OR 1.10, 95% CI 0.74-1.64; p = 0.643) or DOAC versus VKA selection (OR 0.68, 95% CI 0.45-1.01; p = 0.055). However, it was associated with overall DOAC molecule selection (global p = 0.0013), driven by a greater likelihood of dabigatran versus apixaban prescribing (RRR 1.87, 95% CI 1.29-2.72; q = 0.0052). In exploratory dose-specific analyses, prior stroke/TIA was associated with a lower likelihood of rivaroxaban 20 versus 15 mg prescribing (OR 0.54, 95% CI 0.33-0.90; q = 0.047). OAC prescribing increased over time (OR per year 1.16, 95% CI 1.09-1.23), as did DOAC versus VKA prescribing (OR per year 1.30, 95% CI 1.23-1.38; both p < 0.001), accompanied by a shift in DOAC molecule selection toward apixaban. Prior stroke/TIA did not significantly modify temporal prescribing trends, and sensitivity analyses supported the principal findings. Conclusions: Anticoagulant prescribing changed substantially between 2017 and April 2026, with increasing OAC and DOAC use and marked changes in DOAC molecule selection. Prior ischemic stroke/TIA was not independently associated with OAC use or DOAC versus VKA selection and did not significantly modify temporal prescribing trends, although differences were observed in DOAC molecule selection and exploratory dose-specific prescribing. Dose-specific findings describe prescribing patterns and should not be interpreted as assessments of dose appropriateness, efficacy, or safety.