Perspective:

Several studies have demonstrated increased use of OAC for stroke prevention in AF since the introduction of DOAC medications. This study of older patients with Medicare Advantage insurance found similar trends, with nearly all patients being prescribed DOAC medications (as compared to warfarin) by 2020. However, overall use of OAC among older adults remains markedly low, with fewer than 50% receiving any OAC therapy. Use of OAC was even lower among those with ‘high-risk’ features, including dementia, frailty, and anemia. This represents a critical gap in evidence-based care, as older patients are among the highest risk for stroke prevention and several prior analyses have demonstrated favorable risk–benefit ratios. However, this claims-based analysis did not account for patients undergoing left atrial appendage occlusion, which may be a preferable option for many older patients at high risk for both stroke and bleeding. Furthermore, the nonadherence findings should be interpreted cautiously, as the proportion of days covered metric may not be accurate for warfarin given the highly variable dosing schedule. Nonetheless, this analysis confirms that older patients with AF remain vulnerable to untreated stroke risk. Prospective hybrid implementation-effectiveness studies exploring efforts to increase stroke-prevention methods (e.g., anticoagulation, left atrial appendage occlusion) are desperately needed.