74 CHAPTER 5 Secondly, there is still room for improvement in stroke prevention by further reducing OAC undertreatment (i.e. platelet inhibitor monotherapy or no antithrombotic therapy at all) in patients with a CHA2DS2-VASc score ≥2. Finally, the number of NOAC prescriptions is expected to increase further. We observed that the diminishing group of patients who were (still) prescribed a VKA for newonset AF, were older and had more comorbidity (e.g. heart failure, diabetes mellitus and vascular disease) than patients receiving a NOAC, as has also been shown by the GARFIELD-AF registry.21 Moreover, based on performed additional explanatory analyses over time, we concluded that channelling of VKAs over NOACs in older patients and in patients with more comorbidity still took place in 2017, which was the first year in which more new-onset AF patients received a NOAC instead of a VKA (see Supplementary File S4). In the Netherlands, GP guidelines on AF recommend to be cautious when prescribing a NOAC to these frail (aged) patients.27 Although observational data suggest that certain NOACs are as safe as (or safer than) VKAs in frail elderly,28 more research is needed to confirm or refute the current caution in guidelines for this patient group. One such study is already on its way: the randomised controlled FRAIL-AF trial, in which frail AF patients on VKA therapy are switched to a NOAC.29 Nonetheless, it is imaginable that the organisation of care for (frailer) VKA users—in the Netherlands, this is currently provided by the Dutch Thrombosis Services—may have to change in order to guarantee quality and continuity for AF patients who continue to take a VKA, for example by means of integrated management of AF in primary care.26 CONCLUSION Between 2008 and 2017, the prevalence of reported AF in the community more than tripled. Prescription patterns of antithrombotic treatment showed possible channelling of VKAs over NOACs in frailer, elderly patients, whereas still about one in every four patients with a diagnostic code for AF and a CHA2DS2-VASc score ≥2 was not prescribed any prophylactic OAC therapy.
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