Temporal Trends in Stroke-Prevention Medication Use in Patients with Atrial Fibrillation and Chronic Obstructive Pulmonary Disease

Chuan-Wei Shen¹Nantawarn Kitikannakorn²Chung-Yu Chen^1*Buntitabhon Sirichanchuen²Rewadee Jenraumjit²Kuang-Ming Liao³

• ¹School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
• ²Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
• ³Department of Internal Medicine, Chi Mei Hospital Chiali, Tainan City, Taiwan

Background: 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. Methods: Newly diagnosed AF and COPD patients were identified from Taiwan's National Health Insurance Research Database between January 1, 2013, and December 31, 2022. Prescription patterns of stroke-prevention medications within one 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. Results: 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. Conclusion: 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 didn't alter stroke-prevention medication use, though this subgroup warrants attention due to elevated cardiovascular risks.