Socioeconomic Inequalities in Prescription Oral Anticoagulants in Stroke and AF Patients | Journal Scan

Study Questions:

Are there differences in how oral anticoagulants (OACs) are prescribed to patients with atrial fibrillation (AF) after ischemic stroke based on patient sociodemographic factors?


The authors used Swedish national registries to link hospitalization for ischemic stroke, including discharge medications, with sociodemographic information. The study population included patients with AF who had their first ischemic stroke between January 2009 and December 2012, and were not treated with an OAC at the time of the stroke. The primary outcome was prescription of an OAC at discharge, dichotomized to yes/no. OACs included warfarin, dabigatran, rivaroxaban, and apixaban. Level of education and disposable income were used to define socioeconomic status. Country of birth was categorized as Swedish, Nordic (other than Sweden), European (other than Nordic countries), and other. Age, living situation prestroke, activities of daily living (ADL) status, level of consciousness on admission, discharge disposition, and medical comorbidities (smoking, congestive heart failure, diabetes, hypertension, and vascular disease) were also captured. The associations between prescription of an OAC and patient characteristics were analyzed by multivariable logistic regression, controlling for year of stroke, sex, age, country of birth, education, income, living alone, dependency in ADLs, discharge disposition, level of consciousness on admission, and medical comorbidities.


There were 12,088 patients included in the analysis, representing 12% of all stroke patients during the time interval. More than one-third of the patients (36.3%) were prescribed an OAC at discharge, and an additional 3.2% were prescribed an OAC and antiplatelet agent. The following factors were associated with decreased odds of being prescribed an OAC at discharge: older age, lower socioeconomic status, birth outside of Europe (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.40-0.95), birth outside of Nordic countries (OR, 0.80; 95% CI, 0.66-0.96), living alone (OR, 0.79; 95% CI, 0.72-0.87), ADL dependent status (OR, 0.39; 95% CI, 0.32-0.48), not discharged home (OR, 0.36; 95% CI, 0.33-0.40), not alert on admission (OR, 0.68; 95% CI, 0.59-0.78), congestive heart failure (OR, 0.67; 95% CI, 0.58-0.78), diabetes (OR, 0.79; 95% CI, 0.71-0.88), vascular disease (OR, 0.80; 95% CI, 0.73-0.88), and smoking (OR, 0.84; 95% CI, 0.72-0.98).


There are sociodemographic disparities in the prescription of OACs for patients with AF after ischemic stroke that are not related to common stroke risk factors.


AF is a common etiology for ischemic stroke, and strokes caused by AF tend to be more disabling than those caused by other mechanisms. OACs can dramatically reduce the risk of stroke from AF, but these agents are underprescribed. This study suggests that there are disparities in the rate of prescribing OACs for patients with AF after a hospitalization for ischemic stroke. The reasons for these disparities are unclear. While this work is limited in that the authors were not able to evaluate prescriptions for OACs that occurred after discharge, bleeding risk or other contraindications, and was done in Sweden; the results suggest that additional work is needed to reduce the disparities in this area.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Hypertension, Smoking

Keywords: Activities of Daily Living, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Comorbidity, Diabetes Mellitus, Heart Failure, Hospitalization, Hypertension, Platelet Aggregation Inhibitors, Registries, Risk Factors, Secondary Prevention, Smoking, Social Class, Socioeconomic Factors, Stroke, Warfarin

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