Skip to main content

Main menu

  • HOME
  • LATEST ARTICLES
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • RESOURCES
    • About BJGP Open
    • BJGP Open Accessibility Statement
    • Editorial Board
    • Editorial Fellowships
    • Audio Abstracts
    • eLetters
    • Alerts
    • Outreach
    • BJGP Life
    • Research into Publication Science
    • Advertising
    • Contact
    • Top 10 Research Articles of the Year
  • SPECIAL ISSUES
    • Special issue: Telehealth
    • Special issue: Race and Racism in Primary Care
    • Special issue: COVID-19 and Primary Care
    • Past research calls
  • CONFERENCE
  • RCGP
    • British Journal of General Practice
    • BJGP for RCGP members
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Alerts

Search

  • Advanced search
Intended for Healthcare Professionals
BJGP Open
  • RCGP
    • British Journal of General Practice
    • BJGP for RCGP members
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
BJGP Open
Intended for Healthcare Professionals

Advanced Search

  • HOME
  • LATEST ARTICLES
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • RESOURCES
    • About BJGP Open
    • BJGP Open Accessibility Statement
    • Editorial Board
    • Editorial Fellowships
    • Audio Abstracts
    • eLetters
    • Alerts
    • Outreach
    • BJGP Life
    • Research into Publication Science
    • Advertising
    • Contact
    • Top 10 Research Articles of the Year
  • SPECIAL ISSUES
    • Special issue: Telehealth
    • Special issue: Race and Racism in Primary Care
    • Special issue: COVID-19 and Primary Care
    • Past research calls
  • CONFERENCE
Research

Dual antithrombotic therapy and gastroprotection in atrial fibrillation: an observational primary care study

Charis Xuan Xie, John Robson, Crystal Williams, Chris Carvalho, Stuart Rison and Zahra Raisi-Estabragh
BJGP Open 2022; 6 (4): BJGPO.2022.0048. DOI: https://doi.org/10.3399/BJGPO.2022.0048
Charis Xuan Xie
1 Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Charis Xuan Xie
John Robson
2 North East London Integrated Care System, Unex Tower, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Crystal Williams
2 North East London Integrated Care System, Unex Tower, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Chris Carvalho
1 Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
2 North East London Integrated Care System, Unex Tower, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Stuart Rison
1 Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
2 North East London Integrated Care System, Unex Tower, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Stuart Rison
Zahra Raisi-Estabragh
3 Barts Heart Centre, St Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
4 William Harvey Research Institute, National Institute for Health and Care Research Barts Biomedical Research Centre, Queen Mary University London, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Zahra Raisi-Estabragh
  • For correspondence: zahraraisi@doctors.org.uk
  • Article
  • Figures & Data
  • Info
  • eLetters
  • PDF
Loading

Abstract

Background Patients with both atrial fibrillation (AF) and cardiovascular disease (CVD) may receive dual antithrombotic therapy (DAT) with both an anticoagulant and ≥1 antiplatelet agents. Avoiding prolonged duration of DAT and use of gastroprotective therapies reduces bleeding risk.

Aim To describe the extent and duration of DAT and use of gastroprotection in a primary care cohort of patients with AF.

Design & setting Observational study in 1.2 million people registered with GPs across four east London clinical commissioning groups (CCGs), covering prescribing from January 2020–June 2021.

Method In patients with AF, factors associated with DAT prescription, prolonged DAT prescription (>12 months), and gastroprotective prescription were characterised using logistic regression.

Results There were 8881 patients with AF, of whom 4.7% (n = 416) were on DAT. Of these, 65.9% (n = 274) were prescribed DAT for >12 months and 84.4% (n = 351) were prescribed concomitant gastroprotection. Independent of all other factors, females with AF were less likely to receive DAT than males (odds ratio [OR] 0.61, 95% confidence interval [CI] = 0.49 to 0.77). Similarly, older (aged ≥75 years) individuals (OR 0.79, 95% CI = 0.63 to 0.98) were less likely to receive DAT than younger patients. Among those with AF on DAT, pre-existing CVD (OR 3.33, 95% CI = 1.71 to 6.47) and South Asian ethnicity (OR 2.70, 95% CI = 1.15 to 6.32) were associated with increased gastroprotection prescriptions. Gastroprotection prescription (OR 1.80, 95% CI = 1.01 to 3.22) was associated with prolonged DAT prescription.

Conclusion Almost two-thirds of patients with AF on DAT were prescribed prolonged durations of therapy. Prescription of gastroprotection therapies was suboptimal in one in six patients. Treatment decisions varied by sex, age, ethnic group, and comorbidity. Duration of DAT and gastroprotection in patients with AF requires improvement.

  • dual antithrombin therapy
  • anticoagulation
  • antiplatelets
  • atrial fibrillation
  • cardiovascular diseases
  • gastroprotection
  • bleeding risk
  • population health

How this fits in

Patients with AF and CVD may be treated with DAT. Associated bleeding risk may be reduced using gastroprotective therapies and by avoiding prolonged DAT durations. In this large population-based cohort of patients with AF, among those on DAT, two-thirds of patients received treatment for excessive durations and use of gastroprotection therapies was suboptimal. Treatment decisions varied by sex, age, ethnic group, and comorbidity. The findings highlight urgent need for directed strategies to optimise medication management of patients with AF treated with DAT.

Introduction

Ageing populations1 are leading to greater burde from chronic age-related illnesses, among which AF and coronary artery disease (CAD) are the most common CVDs.2,3 These conditions share multiple risk factors and commonly co-exist, presenting clinical challenges.4

Patients with CAD may be prescribed antiplatelets for event prevention in stable disease.5 In the setting of an acute coronary syndrome or after percutaneous coronary intervention (PCI), there is strong evidence for dual antiplatelet therapy to prevent myocardial infarction and, for those undergoing PCI, stent thrombosis.6 High-risk patients with chronic stable CAD also warrant antiplatelet therapy to prevent myocardial infarction or after elective PCI to prevent stent thrombosis.6 The typical duration of dual antiplatelet therapy after PCI is 12 months; however, there is increasing evidence to suggest that shorter durations of therapy are adequate for newer-generation drug-eluting stents and may be considered for patients at high bleeding risk.6

Treatment decisions are further complicated in patients with CAD and co-existent AF, who have an indication for anticoagulation to prevent thromboembolic stroke.4 In these individuals, a short period (1–3 months) of 'triple therapy' (combining dual antiplatelet therapy with anticoagulation) may be recommended, followed by DAT, comprising a single antiplatelet agent and an anticoagulant, for a further 3–11 months.6 Similar clinical challenges are encountered in patients with ischaemic cerebrovascular events with requirement for antiplatelet therapy; these individuals often have co-existent AF, which not infrequently has precipitated the cerebral event. Although durations of DAT vary, it is very rarely indicated for >1 year and for many the appropriate duration is <6 months.4

Concomitant use of multiple antithrombotic therapies is accompanied by increased risk of serious bleeding complications, most commonly upper gastrointestinal bleeding (UGIB). Routine use of gastroprotection therapies and avoiding excessive durations of DAT are important considerations for minimising DAT-related bleeding complications.5–7 However, the frequency with which such simple strategies are adopted in clinical practice is unclear. As most patients with stable chronic diseases are discharged to the community, it is important for both primary care and hospital clinicians to be vigilant to these issues.

UGIB is the commonest cause of hospital admission for an adverse drug-related event of which antiplatelet use, anticoagulant use, and particularly the combination of the two in conjunction with older age are substantive causes.8 A variety of evidence and guidelines now recommend proton pump inhibitors (PPIs) in people at high risk of bleeding on antiplatelet therapy, particularly in combination with anticoagulant therapy.6,9–12

The present study sought to evaluate factors associated with suboptimal bleeding risk mitigation in patients with AF using routine health data in a community setting. This work is particularly timely as the new national Network Contract Directed Enhanced Service Investment and Impact Fund 2020–2021 addresses medicines safety area and includes dual anticoagulant and antiplatelet therapy as a quality indicator for GPs in England.13

A population-based study of patients with AF is presented, describing demographic, physiologic, and clinical factors associated with DAT, and, among those on DAT, prolonged DAT (>12 months) and the prescription of gastroprotective therapies.

Method

Setting and study population

The study population included individuals registered with a GP in one of four east London CCGs (Waltham Forest, City and Hackney, Tower Hamlets, and Newham), covering a total of 1.2 million people. This population comprises individuals who are, on average, younger, more ethnically diverse, and less affluent than the general UK population.14 The CCGs have above national average performance in cardiovascular risk management.14 The study was limited to adults aged ≥18 years. Individuals were excluded who were registered with GPs for <12 months from the date of data extraction. Individuals were included with a record of diagnosed AF or atrial flutter, as per standardised SNOMED-CT codes (see Supplementary Table S1). Patients with a record of 'Atrial fibrillation resolved' were excluded.

Data source

Deidentified health data were provided by the Clinical Effectiveness Group at Queen Mary University of London, who centrally extracted pseudonymised data from the general practice systems (EMIS) in June 2021, covering prescribing in the period from January 2020–June 2021. Data analysis was conducted in July 2021. Cases, demographic, and other risk factors and medication were identified using SNOMED-CT codes and routinely collected data.

DAT and gastric protection medications

DAT was defined as concomitant prescription of ≥1 antiplatelet medications (aspirin, clopidogrel, dipyridamole, prasugrel, and ticagrelor) and an anticoagulant (warfarin, phenindione, acenocoumarol, apixaban, dabigatran, edoxaban, and rivaroxaban) within the preceding 6 months. Individuals prescribed DAT for >12 months were identified using an algorithm identifying prescription of both an anticoagulant and an antiplatelet medicine at both 18 months and within 6 months before data extraction. Prescription of gastroprotection medications in the preceding 6 months was additionally noted, specifically, PPIs (pantoprazole, rabeprazole, omeprazole, and esomeprazole), or H2-receptor antagonists (H2RAs: ranitidine, cimetidine, and famotidine).

Risk factor indicators

Two age categories were considered of above and below 75 years, sex was defined as male or female, and five ethnic groups were considered aligned with the Office for National Statistics (ONS) 2001 census ethnic group classification:15 1) White (British, Irish, any other White background); 2) Black (Caribbean, African, any other Black background); 3) South Asian (Indian, Pakistani, Bangladeshi, any other Asian background); 4) other ethnic groups including mixed ethnic groups and Chinese; and 5) those with no record of coded ethnic group.16 Deprivation was measured by the Index of Multiple Deprivation (IMD) 2015 and individuals were grouped into locally derived quintiles, from least (1) to most (5) deprived.17

Smoking history was classified as current smoker, ex-smoker, or never smoked (ever recorded). Body mass index (BMI) was directly extracted or calculated from records of height and weight. BMI was categorised into World Health Organization categories of obesity: <20 kg/m2 (underweight); 20–29 kg/m2 (reference level); and ≥30 kg/m2 (obese). Systolic blood pressure was extracted from recorded office measurements and classified into above and below 140 mmHg. All characteristics considered were based on the latest record within the past 3 years.

The following conditions were included, selected on their likely influence on clinical decisions regarding antithrombotic and gastroprotection therapies: ischaemic heart disease (IHD), stroke or transient ischaemic attack (TIA), diabetes (type 1 or type 2), chronic kidney disease (CKD), and previous UGIB. Disease definitions were based on relevant SNOMED-CT codes (see Supplementary Table S1).

Statistical analysis

Statistical analyses were conducted using Stata (version 17.0). The association of clinical, physiological, and demographic factors with DAT prescription were estimated among patients with AF. Logistic regression models were used with DAT status (yes or no) set as the model outcome and participant characteristics set as the exposures of interest. Additionally, the study examined, among patients with AF on DAT, factors associated with prescription of gastroprotective therapy using logistic regression models, setting the model outcome as gastroprotection (yes or no) and inserting participant characteristics as the exposures of interest. Analyses were performed first in univariable and then in multivariable models with mutual adjustment for all exposures (age, sex, ethnic group, deprivation, CVD [IHD, stroke, or TIA], diabetes or stage 3–5 CKD, UGIB, systolic blood pressure, smoking, and BMI). Subgroup analysis was performed in patients prescribed DAT for 6 months and >12 months. Missing fields were treated as a separate category, ‘unknown’, in the univariable and multivariable logistic regression models without losing this information. Where the number of patients with missing data was very small (that is, <5) these patients were excluded from the model and indicated in the footnotes. The study reports ORs with 95% CIs and the corresponding P-values. Statistical significance level was set at 5%. The study conformed to the STROBE criteria.18

Results

Sample characteristics

A total of 8881 patients with AF were included in the analysis (Table 1 and Supplementary Figure S1). Almost half the patients (n = 4300/8881, 48.4%) were aged ≥75 years. There were slightly more males than females (n = 5024/8881, 56.6%). The degree of ethnic diversity was greater than in the national UK population with 36.6% (n = 3253/8881) of patients from ethnic minority backgrounds, most commonly from Black (n = 1186/8881, 13.4%) and South Asian (n = 1069/8881, 12.0%) ethnic groups. There was high prevalence of comorbidities, with diabetes or CKD recorded in 49.4% (n = 4389/8881) and CVD (IHD, stroke, or TIA) in 35.8% (n = 3177/8881). There was a record of obesity (BMI ≥30 kg/m2) in 33.8% (n = 3002/8881) of individuals. The sample included 8.9% (n = 792/8881) current smokers and 30.9% (n = 2742/8881) ex-smokers. Latest recorded systolic blood pressure measurement was ≥140 mmHg for 14.2% (n = 1262/8881) of patients.

View this table:
  • View inline
  • View popup
Table 1. Baseline patient characteristics of individuals with AF stratified by DAT prescription

A total of 416 (4.7%) patients were on DAT. The majority had documented CVD (n = 340/416, 81.7%). Patients on DAT had substantially poorer cardiometabolic profile and more demographic and other vascular risk factors than the rest of the cohort. Among those on DAT, 65.9% (n = 274/416) were issued prescriptions for >12 months. Among those on DAT, 84.4% (n = 351/416) were on gastroprotection therapies; the proportion of these patients on DAT with a history of UGIB did not appear markedly different to the rest of the AF cohort not on DAT (1.4% [n = 6/416] versus 1.2% [n = 105/8465]) (Table 1).

DAT

In fully adjusted multivariable logistic regression models (Table 2), male sex, younger age, South Asian ethnic group, CVD, diabetes or CKD, current smoking, and obesity (BMI ≥30 kg/m2) were all independently associated with greater likelihood of DAT. Individuals with CVD were over 8-fold (OR 8.01; 95% CI = 6.17 to 10.39; P<0.001) more likely to receive DAT compared with those without CVD. Independent of all other factors, females with AF were significantly less likely to receive DAT than males (OR 0.61; 95% CI = 0.49 to 0.77; P<0.001), as were older individuals (OR 0.79; 95% CI = 0.63 to 0.98; P = 0.032) compared with younger patients.

View this table:
  • View inline
  • View popup
Table 2. Logistic regression models estimating the association of patient-related factors with DAT prescription among individuals with AF

Prolonged DAT

Most patients with AF on DAT had a record of dual prescriptions for >12 months (n = 274/416, 65.9%). Patient characteristics stratified by DAT duration are displayed in Supplementary Table S2. Among those on prolonged DAT, there was a disproportionate number of males (73.0% [n = 200/274] versus 60.6% [n = 86/142]), younger individuals (53.6% [n = 147/274] versus 49.3% [n = 70/142]), and individuals from South Asian ethnic backgrounds (24.5%% [n = 67/274] versus 18.3% [n = 26/142]). Those with CVD were more likely to be on prolonged DAT (85.0% [n = 233/274] versus 75.4% [n = 107/142]). The rates of UGIB did not differ among those on prolonged DAT compared with those on shorter DAT durations (1.5% [n = 4/274] versus 1.4% [n = 2/142]). In multivariable linear regression models (Table 3), prescription of gastroprotection therapies (PPI or H2RAs) was significantly associated with DAT duration of >12 months (OR 1.80; 95% CI = 1.01 to 3.22; P = 0.048). Apart from this, statistically significant associations were not observed between any of the other exposures and DAT duration in univariable or multivariable models.

View this table:
  • View inline
  • View popup
Table 3. Logistic regression models estimating the association of patient-related factors associated with DAT duration >12 months (versus <6 months) in individuals with AF

Gastric protection

Among the 416 patients with AF on DAT, 84.4% (n = 351) were prescribed gastroprotection (PPIs or H2RAs); of these 346 (98.6%) were prescribed PPI and five (1.4%) patients were prescribed H2RA alone. The characteristics of this subset is presented in Supplementary Table S3. Those receiving gastroprotection were more likely to be female (31.9% [n = 112/351] versus 27.7% [n = 18/65]), from ethnic minority backgrounds (48.7% [n = 171/351] versus 35.4% [n = 23/65]), and to have comorbidities, including CVD, diabetes, CKD, or previous UGIB (see Supplementary Table S3).

In fully adjusted models (Table 4), those with CVD were over 3-fold more likely to receive gastroprotection (OR 3.33; 95% CI = 1.71 to 6.47; P<0.001), compared with those without CVD. Similarly, independent of all other exposures, individuals from a South Asian ethnic group were significantly more likely to receive PPI or H2RA prescriptions (OR 2.70; 95% CI = 1.15 to 6.32; P = 0.023) compared with those from White ethnic backgrounds.

View this table:
  • View inline
  • View popup
Table 4. Logistic regression models estimating the association of patient-related factors associated with PPI/H2RA prescription in individuals with AF on DAT

Discussion

Summary

In this large population-based cohort of 8881 patients with AF, 4.7% (n = 416) were on DAT. Male sex, younger age, South Asian ethnic group, CVD, diabetes or CKD, current smoking, and obesity were all independently associated with greater likelihood of DAT. Independent of all other factors, female and older patients with AF were significantly less likely to receive DAT than male and younger patients. Among patients with AF on DAT, almost two-thirds (65.9%, n = 274/416) received prescriptions for >12 months, which indicates an inappropriately prolonged duration. Greater use of PPI or H2RA was the only factor significantly linked to prolonged DAT prescription. Among patients with AF on DAT, 84.4% (n = 351/416) were on gastroprotective therapies (PPI or H2RAs). The presence of CVD (IHD, stroke, or TIA) was associated with greater likelihood of PPI or H2RA.

Strengths and limitations

This large-scale epidemiologic study of routine primary care health data allowed examination of treatment practices in an ethnically diverse population cohort. The use of standardised disease codes and complete prescription records supported reliable ascertainment of case and treatment status across a large, unselected sample. Use of routine data may have some limitations. Ascertainment of AF cases may be limited by misdiagnoses or coding errors. Furthermore, the study defined DAT and PPI or H2RA use based on primary care prescription records, without assessment of medication adherence. It is also possible that a small minority of patients were using medications obtained from sources other than primary care or were using medications issued outside of the analysis window. Such individuals would not be captured in the study, but are unlikely to be in numbers to appreciably alter the results. It was assumed that concurrent prescription of medications indicates concurrent usage. While for most people this would be correct, it is possible that some people were categorised as DAT users but had in fact discontinued their antiplatelet medicine. The definition of prolonged DAT (>12 months) does not account for individuals who may have stopped and restarted DAT for an appropriate indication. Finally, very uncommonly, extended DAT may be appropriate. Patient records were unable to be viewed individually and patients on appropriate prolonged DAT or who received DAT prescriptions but did not actually take the medication could not be distinguished. However, the number of such individuals is likely to be small and would not explain the large proportion of patients on prolonged DAT in the cohort (n = 274, 65.9% of those on DAT). The study did not consider the further duration of therapy beyond 12 months as for the vast majority this is clearly an excessive duration. Future work considering more granular risk would be informative, but information electronically coded in UK GP records is limited to the issue of a prescription and there is no adequate record of patients not completing prescriptions.

There are many factors that may influence bleeding risk. This article aimed to provide a broad characterisation of individuals who were prescribed DAT; the clinical factors considered in this study are not exhaustive. A key outcome in evaluating DAT is the frequency of UGIB. The few UGIB events in the sample precluded comparisons with this outcome. Finally, the sample from east London has greater ethnic diversity, deprivation, and comorbidities than the national UK population. Similar evaluations at a national level would provide further insight on the topic.

Comparison with existing literature

The risk factors associated with DAT in the study are consistent with previous reports.19–22 Among patients with AF on DAT, 81.7% (n = 340/416) had co-existent CVD (IHD, stroke, or TIA). There were 76 patients (18.3%) who were on DAT, but without documented CVD; it was noted that these individuals were significantly less likely to receive PPI or H2RA than those with record of CVD. It is possible that CVDs were present but are not correctly coded for these patients or that they have alternative, less common indications for antiplatelet therapy such as peripheral arterial disease or haematological diseases. Either way, the findings suggest that for these patients the indication for DAT was unclear and associated with lower rates of gastroprotection prescription.

A record of DAT was found in 4.7% (n = 416) of the study sample. This is lower than in previous studies and indicates a decreasing contemporary trend when compared with other nationwide studies dating from >10 years earlier. Previous reports from UK data between 1998 and 2010 indicate that 11% of patients with AF and IHD were on DAT.23 In a similar population of patients with AF and IHD between 2010 and 2011, rates of DAT were reported at 27%.24 Corresponding figures from Japan25 (2016–2018) and Italy26 (2018–2019) are 15.1% and 8.8%, respectively. A key difference between the present studies and these reports is that the latter are all limited to individuals with AF and IHD, in whom guideline recommendations for DAT are generally well-defined. The current study included all patients with those with AF and as such a lower proportion on DAT would be expected. Other potential explanations include differences in study populations, more contemporary results, and differences in national practices.

Among patients with AF on DAT, 84.4% (n = 351) were prescribed a PPI or H2RA, which is higher than reported by other cohort studies (11%–63%).25,27,28 A relatively high figure was achieved possibly by virtue of a local incentive programme promoting the use of PPI optimisation, or simply because contemporary guidance and research is more likely to endorse the use of PPI co-therapy with antithrombic medicines. Indeed, a recent European Society of Cardiology guidance update highlighted bleeding risk reduction as a key priority area, including recommendation for routine use of PPI in combined uses of antiplatelet agents with either another antiplatelet drug or an anticoagulant.6 As indicated in the above discussion, prescription of DAT was significantly higher in patients with documented CVD, indicating that perhaps these patients had clearer healthcare plans.

Independent of all other demographic and clinical factors, women with AF had significantly lower rates of DAT prescription than males (5.7% versus 3.4%), which may suggest undertreatment of women. Previous work has demonstrated underdiagnosis,29 undertreatment, and delayed treatment of women with CVD compared with men.30,31 Poorer risk factor profile and IHD patterns associated with higher thrombotic risk32–36 were not evaluated in the current study, and may be driving greater use of DAT in males. Additionally, greater perception of bleeding risk in women may be driving a reluctance for DAT in this cohort. Indeed, among women prescribed DAT, greater use of gastric protection therapies were observed than in men (31.9% versus 27.3%), although this difference was not statistically significant. There are likely to be other factors influencing sex-differential practices, which would be a subject for further research.

Implications for research and practice

The findings underline several key management considerations. Among patients with AF, 4.7% were receiving DAT, of these, over 65% were prescribed DAT for inappropriately prolonged durations. This highlights the importance of clear documentation of indications for DAT and its duration, with a requirement for continuing regular review of any DAT use beyond 6 months. Although higher rates of PPI or H2RA prescription in those on prolonged DAT were observed, further research is indicated to investigate the efficacy of PPI/H2RA in prolonged durations of DAT. Second, 16% of patients on DAT were not prescribed PPI or H2RA. Gastroprotection therapy should be routinely recommended for older patients receiving multiple antithrombotic agents or those with other UGIB risk factors.37,38 Finally, it was observed that woemn were significantly less likely to receive DAT, even when all other patient-related factors were accounted for; possible undertreatment of females warrants further study.

Notes

Funding

This work was supported by the Wellcome Trust (reference: 224863/Z/21/Z); Barts Charity and Health Data Research UK, an initiative funded by UK Research and Innovation, Department of Health and Social Care (England) and the devolved administrations, and leading medical research charities. Charis Xuan Xie is funded by the Wellcome Trust (reference: 224863/Z/21/Z). John Robson, Stuart Rison, Crystal Williams, and Chris Carvalho are employed by Queen Mary University of London. Stuart Rison and John Robson were supported by Barts Charity. John Robson and Crystal Williams were supported by Health Data Research UK. Zahra Raisi-Estabragh recognises the National Institute for Health and Care Research (NIHR) Integrated Academic Training programme, which supports her Academic Clinical Lectureship post, and was also supported by a British Heart Foundation Clinical Research Training Fellowship (reference: FS/17/81/33318).

Patient consent

There was no involvement from patients or the public in the design, conduct, or outcome of this work.

Ethical approval

This study is based on deidentified information obtained from routinely compiled GP electronic health records and did not require ethics committee approval.

Provenance

Freely submitted; externally peer reviewed.

Data

The dataset relied on in this article is available from the corresponding author on reasonable request.

Acknowledgements

The authors are grateful to the GPs and their practice teams for allowing the use of their patient records, to the Clinical Effectiveness Group for providing access to their curated high-quality dataset, and to the population in east London from whom the data are derived.

Competing interests

The authors declare that no competing interests exist.

Disclosure

The authors report no conflicts of interest in this work

  • Received April 6, 2022.
  • Revision received April 6, 2022.
  • Accepted May 6, 2022.
  • Copyright © 2022, The Authors

This article is Open Access: CC BY license (https://creativecommons.org/licenses/by/4.0/)

References

  1. 1.↵
    1. World Health Organization
    (2011) Global health and aging. accessed. https://www.nia.nih.gov/sites/default/files/2017-06/global_health_aging.pdf. 13 Sep 2022.
  2. 2.↵
    1. Yarnall AJ,
    2. Sayer AA,
    3. Clegg A,
    4. et al.
    (2017) New horizons in multimorbidity in older adults. Age Ageing 46 (6):882–888, doi:10.1093/ageing/afx150.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Roth GA,
    2. Abate D,
    3. Abate KH,
    4. Abay SM
    (2018) Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 392 (10159):1736–1788, doi:10.1016/S0140-6736(18)32203-7.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Hindricks G,
    2. Potpara T,
    3. Dagres N,
    4. et al.
    (2021) 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 42 (5):373–498, doi:10.1093/eurheartj/ehaa612.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Knuuti J,
    2. Wijns W,
    3. Saraste A,
    4. et al.
    (2020) 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 41 (3):407–477.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Valgimigli M,
    2. Bueno H,
    3. Byrne RA,
    4. et al.
    (2018) Special article 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Rev Esp Cardiol (Engl Ed) 71 (1):42, doi:10.1016/j.rec.2017.11.020.
    OpenUrlCrossRef
  7. 7.↵
    1. Guo H,
    2. Ye Z,
    3. Huang R
    (2021) Clinical outcomes of concomitant use of proton pump inhibitors and dual antiplatelet therapy: a systematic review and meta-analysis. Front Pharmacol 12 doi:10.3389/fphar.2021.694698. 694698.
    OpenUrlCrossRef
  8. 8.↵
    1. Pirmohamed M,
    2. James S,
    3. Meakin S,
    4. et al.
    (2004) Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 329 (7456):15–19, doi:10.1136/bmj.329.7456.15.
    OpenUrlAbstract/FREE Full Text
  9. 9.↵
    1. Li L,
    2. Geraghty OC,
    3. Mehta Z,
    4. et al.
    (2017) Age-specific risks, severity, time course, and outcome of bleeding on long-term antiplatelet treatment after vascular events: a population-based cohort study. Lancet 390 (10093):490–499, doi:10.1016/S0140-6736(17)30770-5.
    OpenUrlCrossRefPubMed
  10. 10.
    1. Abraham NS,
    2. Hlatky MA,
    3. Antman EM,
    4. et al.
    (2010) ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation 122 (24):2619–2633, doi:10.1161/CIR.0b013e318202f701.
    OpenUrlFREE Full Text
  11. 11.
    1. Ray WA,
    2. Chung CP,
    3. Murray KT,
    4. et al.
    (2016) Association of proton pump inhibitors with reduced risk of warfarin-related serious upper gastrointestinal bleeding. Gastroenterology 151 (6):1105–1112, doi:10.1053/j.gastro.2016.08.054.
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Vaduganathan M,
    2. Cannon CP,
    3. Cryer BL,
    4. et al.
    (2016) Efficacy and safety of proton-pump inhibitors in high-risk cardiovascular subsets of the COGENT trial. Am J Med 129 (9):1002–1005, doi:10.1016/j.amjmed.2016.03.042.
    OpenUrlCrossRefPubMed
  13. 13.↵
    1. NHS England
    (2020) Network Contract Directed Enhanced Service: Investment and Impact Fund 2020/21: guidance. accessed. https://www.england.nhs.uk/wp-content/uploads/2020/09/IIF-Implementation-Guidance-2020-21-Final.pdf. 13 Sep 2022.
  14. 14.↵
    1. Robson J,
    2. Hull S,
    3. Mathur R,
    4. Boomla K
    (2014) Improving cardiovascular disease using managed networks in general practice: an observational study in inner london. Br J Gen Pract 64 (622):e268–e274, doi:10.3399/bjgp14X679697.
    OpenUrlAbstract/FREE Full Text
  15. 15.↵
    1. UK Government
    List of ethnic groups. accessed. https://www.ethnicity-facts-figures.service.gov.uk/style-guide/ethnic-groups#2001-census. 13 Sep 2022.
  16. 16.↵
    1. Office for National Statistics
    Ethnic group, national identity and religion. accessed. https://www.ons.gov.uk/methodology/classificationsandstandards/measuringequality/ethnicgroupnationalidentityandreligion. 13 Sep 2022.
  17. 17.↵
    1. Ministry of Housing, Communities and Local Government
    (2019) English indices of deprivation 2019. accessed. https://www.gov.uk/government/statistics/english-indices-of-deprivation-2019. 13 Sep 2022.
  18. 18.↵
    1. von Elm E,
    2. Altman DG,
    3. Egger M,
    4. et al.
    (2007) Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 335 (7624):806–808, doi:10.1136/bmj.39335.541782.AD.
    OpenUrlFREE Full Text
  19. 19.↵
    1. Steinberg BA,
    2. Kim S,
    3. Piccini JP,
    4. et al.
    (2013) Use and associated risks of concomitant aspirin therapy with oral anticoagulation in patients with atrial fibrillation: insights from the outcomes registry for better informed treatment of atrial fibrillation (ORBIT-AF) registry. Circulation 128 (7):721–728, doi:10.1161/CIRCULATIONAHA.113.002927.
    OpenUrlAbstract/FREE Full Text
  20. 20.
    1. So CH,
    2. Eckman MH
    (2017) Combined aspirin and anticoagulant therapy in patients with atrial fibrillation. J Thromb Thrombolysis 43 (1):7–17, doi:10.1007/s11239-016-1425-5.
    OpenUrlCrossRef
  21. 21.
    1. Lamberts M,
    2. Gislason GH,
    3. Lip GYH,
    4. et al.
    (2014) Antiplatelet therapy for stable coronary artery disease in atrial fibrillation patients taking an oral anticoagulant: a nationwide cohort study. Circulation 129 (15):1577–1585, doi:10.1161/CIRCULATIONAHA.113.004834.
    OpenUrlAbstract/FREE Full Text
  22. 22.↵
    1. Kebernik J,
    2. Borlich M,
    3. Tölg R,
    4. et al.
    (2018) Dual antithrombotic therapy with clopidogrel and novel oral anticoagulants in patients with atrial fibrillation undergoing percutaneous coronary intervention: a real-world study. Cardiol Ther 7 (1):79–87, doi:10.1007/s40119-018-0108-z.
    OpenUrlCrossRef
  23. 23.↵
    1. Pasea L,
    2. Chung S-C,
    3. Pujades-Rodriguez M,
    4. et al.
    (2019) Bleeding in cardiac patients prescribed antithrombotic drugs: electronic health record phenotyping algorithms, incidence, trends and prognosis. BMC Med 17 (1), doi:10.1186/s12916-019-1438-y. 206.
    OpenUrlCrossRef
  24. 24.↵
    1. Lopes RD,
    2. Rao M,
    3. Simon DN,
    4. et al.
    (2016) Triple vs dual antithrombotic therapy in patients with atrial fibrillation and coronary artery disease. Am J Med 129 (6):592–599, doi:10.1016/j.amjmed.2015.12.026.
    OpenUrlCrossRefPubMed
  25. 25.↵
    1. Mizokami Y,
    2. Yamamoto T,
    3. Atarashi H,
    4. et al.
    (2020) Current status of proton pump inhibitor use in Japanese elderly patients with non-valvular atrial fibrillation: a subanalysis of the ANAFIE registry. PLoS One 15 (11), doi:10.1371/journal.pone.0240859. e0240859.
    OpenUrlCrossRef
  26. 26.↵
    1. De Luca L,
    2. Rubboli A,
    3. Bolognese L,
    4. et al.
    (2020) Antithrombotic management of patients with acute coronary syndrome and atrial fibrillation undergoing coronary stenting: a prospective, observational, nationwide study. BMJ Open 10 (12), doi:10.1136/bmjopen-2020-041044. e041044.
    OpenUrlAbstract/FREE Full Text
  27. 27.↵
    1. Hansen ML,
    2. Sørensen R,
    3. Clausen MT,
    4. et al.
    (2010) Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med 170 (16):1433–1441, doi:10.1001/archinternmed.2010.271.
    OpenUrlCrossRefPubMed
  28. 28.↵
    1. Yasuda S,
    2. Kaikita K,
    3. Akao M,
    4. et al.
    (2019) Antithrombotic therapy for atrial fibrillation with stable coronary disease. N Engl J Med 381 (12):1103–1113, doi:10.1056/NEJMoa1904143.
    OpenUrlCrossRefPubMed
  29. 29.↵
    1. Wu J,
    2. Gale CP,
    3. Hall M,
    4. et al.
    (2018) Editor’s choice — Impact of initial hospital diagnosis on mortality for acute myocardial infarction: a national cohort study. Eur Heart J Acute Cardiovasc Care 7 (2):139–148, doi:10.1177/2048872616661693.
    OpenUrlCrossRefPubMed
  30. 30.↵
    1. Skelding KA,
    2. Boga G,
    3. Sartorius J,
    4. et al.
    (2013) Frequency of coronary angiography and revascularization among men and women with myocardial infarction and their relationship to mortality at one year: an analysis of the Geisinger myocardial infarction cohort. J Interv Cardiol 26 (1):14–21, doi:10.1111/joic.12009.
    OpenUrlCrossRef
  31. 31.↵
    1. Zhao M,
    2. Woodward M,
    3. Vaartjes I,
    4. et al.
    (2020) Sex differences in cardiovascular medication prescription in primary care: a systematic review and meta-analysis. J Am Heart Assoc 9 (11), doi:10.1161/JAHA.119.014742. e014742.
    OpenUrlCrossRefPubMed
  32. 32.↵
    1. Haider A,
    2. Bengs S,
    3. Luu J,
    4. et al.
    (2020) Sex and gender in cardiovascular medicine: presentation and outcomes of acute coronary syndrome. Eur Heart J 41 (13):1328–1336, doi:10.1093/eurheartj/ehz898.
    OpenUrlCrossRefPubMed
  33. 33.
    1. Bhatnagar P,
    2. Wickramasinghe K,
    3. Wilkins E,
    4. Townsend N
    (2016) Trends in the epidemiology of cardiovascular disease in the UK. Heart 102 (24):1945–1952, doi:10.1136/heartjnl-2016-309573.
    OpenUrlAbstract/FREE Full Text
  34. 34.
    1. Garcia M,
    2. Mulvagh SL,
    3. Bairey Merz CN,
    4. et al.
    (2016) Cardiovascular disease in women: clinical perspectives. Circ Res 118 (8):1273–1293, doi:10.1161/CIRCRESAHA.116.307547.
    OpenUrlAbstract/FREE Full Text
  35. 35.
    1. Gerdts E,
    2. Regitz-Zagrosek V
    (2019) Sex differences in cardiometabolic disorders. Nat Med 25 (11):1657–1666, doi:10.1038/s41591-019-0643-8.
    OpenUrlCrossRef
  36. 36.↵
    1. Lip GYH,
    2. Windecker S,
    3. Huber K,
    4. et al.
    (2014) Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of cardiology Working group on thrombosis, European heart rhythm association (EHRA), European association of percutaneous cardiovascular interventions (EAPCI) and European association of acute cardiac care (ACCA) endorsed by the heart rhythm Society (HRS) and Asia-Pacific heart rhythm Society (APHRS). Eur Heart J 35 (45):3155–3179.
    OpenUrlCrossRefPubMed
  37. 37.↵
    1. Kurlander JE,
    2. Gu X,
    3. Scheiman JM,
    4. et al.
    (2019) Missed opportunities to prevent upper GI hemorrhage: the experience of the Michigan anticoagulation quality improvement initiative. Vasc Med 24 (2):153–155, doi:10.1177/1358863X18815971.
    OpenUrlCrossRef
  38. 38.↵
    1. Causada-Calo N,
    2. Germini F,
    3. Yuan Y,
    4. et al.
    (2019) Proton-pump inhibitors for the prevention of upper gastrointestinal bleeding in adults receiving antithrombotic therapy. Cochrane Database Syst Rev 8 doi:10.1002/14651858.CD013415. CD013415.
    OpenUrlCrossRef
Back to top
Previous ArticleNext Article

In this issue

BJGP Open
Vol. 6, Issue 4
December 2022
  • Table of Contents
  • Index by author
Download PDF
Email Article

Thank you for recommending BJGP Open.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Dual antithrombotic therapy and gastroprotection in atrial fibrillation: an observational primary care study
(Your Name) has forwarded a page to you from BJGP Open
(Your Name) thought you would like to see this page from BJGP Open.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Dual antithrombotic therapy and gastroprotection in atrial fibrillation: an observational primary care study
Charis Xuan Xie, John Robson, Crystal Williams, Chris Carvalho, Stuart Rison, Zahra Raisi-Estabragh
BJGP Open 2022; 6 (4): BJGPO.2022.0048. DOI: 10.3399/BJGPO.2022.0048

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Dual antithrombotic therapy and gastroprotection in atrial fibrillation: an observational primary care study
Charis Xuan Xie, John Robson, Crystal Williams, Chris Carvalho, Stuart Rison, Zahra Raisi-Estabragh
BJGP Open 2022; 6 (4): BJGPO.2022.0048. DOI: 10.3399/BJGPO.2022.0048
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • Abstract
    • How this fits in
    • Introduction
    • Method
    • Results
    • Discussion
    • Notes
    • References
  • Figures & Data
  • Info
  • eLetters
  • PDF

Keywords

  • dual antithrombin therapy
  • anticoagulation
  • antiplatelets
  • atrial fibrillation
  • cardiovascular diseases
  • gastroprotection
  • bleeding risk
  • population health

More in this TOC Section

  • Translating primary care to telehealth: analysis of in-person consultations on diabetes and cardiovascular disease
  • Primary care physicians’ perceptions of social determinants of health recommendations: a qualitative study
  • Ethnic minority GP trainees at risk for underperformance assessments: a quantitative cohort study
Show more Research

Related Articles

Cited By...

Intended for Healthcare Professionals

@BJGPOpen's Likes on Twitter

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Latest articles
  • Authors & reviewers
  • Accessibility statement

RCGP

  • British Journal of General Practice
  • BJGP for RCGP members
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP Open
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP Open: research
  • Writing for BJGP Open: practice & policy
  • BJGP Open editorial process & policies
  • BJGP Open ethical guidelines
  • Peer review for BJGP Open

CUSTOMER SERVICES

  • Advertising
  • Open access licence

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Open Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: bjgpopen@rcgp.org.uk

BJGP Open is an editorially-independent publication of the Royal College of General Practitioners

© 2023 BJGP Open

Online ISSN: 2398-3795