Contemporary data have shown a decrease in the ischaemic stroke risk associated with female sex in patients with atrial fibrillation (AF). We evaluated temporal trends in the predictive value of a non-sex CHA₂DS₂-VASc risk score (ie. CHA₂DS₂-VA). The FinACAF study covers all patients with incident AF between 2007 and 2018 in Finland from all levels of care. The CHA₂DS₂-VA score was compared with the CHA₂DS₂-VASc using continuous and category-based net reclassification indices (NRIs), integrated discrimination improvement (IDI), c-statistics and decision curve analyses. We identified 144,879 anticoagulant naïve patients with new-onset AF between 2007 and 2018 (49.9% women; mean age 72.1 years), of whom 3936 (2.7%) experienced ischaemic stroke during one-year follow-up. Based on both continuous and category-based NRIs, the CHA₂DS₂-VA score was inferior to the CHA₂DS₂-VASc in the early years (−0.333 (95% CI −0.411 to −0.261) and −0.118 (95% CI −0.137 to −0.099), respectively). However, the differences attenuated over time, and by the end of the study period, the continuous NRI became non-significant (−0.093 (95% CI −0.165 to 0.032)), whereas the category-based NRI reversed in favor of the CHA₂DS₂-VA (0.070 (95% CI 0.048–0.087)). The IDI was non-significant in early years (0.0009 (95% CI −0.0024 to 0.0037)), but over time became statistically significant in favor of the CHA₂DS₂-VA score (0.0022 (95% CI 0.0001–0.0044)). The Cox models fitted with the CHA₂DS₂-VA and the CHA₂DS₂-VASc scores exhibited comparable discriminative capability in the beginning of the study (p-value 0.63), but over time marginal differences in favor of the CHA₂DS₂-VA score emerged (p-value 0.0002). In 2007–2008 (when females had higher AF-related stroke risks than males), the CHA₂DS₂-VASc score outperformed the CHA₂DS₂-VA score, but the initial differences between the scores attenuated over time. By the end of the study period in 2017–2018 (with limited/no sex differences in AF-related stroke), there was marginal superiority for the CHA₂DS₂-VA score. This work was supported by the 10.13039/100010133 Aarne Koskelo Foundation , The Finnish Foundation for Cardiovascular Research, The Finnish State Research funding, and Helsinki and Uusimaa Hospital District research fund.

Female sex has been linked with higher risk of ischaemic stroke (IS) in atrial fibrillation (AF), but no prior study has examined temporal trends in the IS risk associated with female sex. The registry-linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) study included all patients with AF in Finland from 2007 to 2018. Ischaemic stroke rates and rate ratios were computed. Overall, 229 565 patients with new-onset AF were identified (50.0% women; mean age 72.7 years). The crude IS incidence was higher in women than in men across the entire study period (21.1 vs. 14.9 events per 1000 patient-years, P < .001), and the incidence decreased both in men and women. In 2007–08, female sex was independently associated with a 20%–30% higher IS rate in the adjusted analyses, but this association attenuated and became statistically non-significant by the end of the observation period. Similar trends were observed when time with and without oral anticoagulant (OAC) treatment was analysed, as well as when only time without OAC use was considered. The decrease in IS rate was driven by patients with high IS risk, whereas in patients with low or moderate IS risk, female sex was not associated with a higher IS rate. The association between female sex and IS rate has decreased and become non-significant over the course of the study period from 2007 to 2018, suggesting that female sex could be omitted as a factor when estimating expected IS rates and the need for OAC therapy in patients with AF. Temporal trends in the association between female sex and ischaemic stroke among patients with atrial fibrillation in Finland from 2007 to 2018.

CHA₂DS₂-VASc [congestive heart failure, hypertension, age ≥75 years (doubled), diabetes, stroke/transient ischaemic attack/thromboembolism (doubled), vascular disease, age 65–74 years, sex category (female)]; CHA₂DS₂-VA [congestive heart failure, hypertension, age ≥75 years (doubled), diabetes, stroke/transient ischaemic attack/thromboembolism (doubled), vascular disease, age 65–74 years]; CHD-VASc [congestive heart failure, hypertension, diabetes, stroke/transient ischaemic attack/thromboembolism (doubled), vascular disease, age 65–74 years, sex category (female)]; CHD-VA [congestive heart failure, hypertension, diabetes, stroke/transient ischaemic attack/thromboembolism (doubled), vascular disease, age 65–74 years].

Aims: Guidelines on the management of atrial fibrillation (AF) have evolved significantly during the past two decades, but the concurrent developments in real-life management and prognosis of AF are unknown. We assessed trends in the treatment and outcomes of patients with incident AF between 2007 and 2017. Methods and results: The registry-based nationwide FinACAF (Finnish AntiCoagulation in Atrial Fibrillation) cohort covers all patients with AF in Finland from all levels of care. We determined the proportion of patients who were treated with oral anticoagulants (OACs) or rhythm control therapies, experienced an ischaemic stroke or bleeding event requiring hospitalization, or died within 1-year follow-up after AF diagnosis. We identified 206 909 patients (mean age 72.6 years) with incident AF. During the study period, use of OACs increased from 43.6 to 76.3%, and the increase was most evident in patients with at least moderate stroke risk. One-year mortality decreased from 13.3 to 10.6%, and the ischaemic stroke rate from 5.3 to 2.2%. The prognosis especially improved in patients over 75 years of age. Concurrently, a small increase in major bleeding events was observed. Use of catheter ablation increased continuously over the study period, but use of other rhythm-control therapies decreased after 2013. Conclusion: Stroke prevention with OACs in patients with incident AF improved considerably from 2007 to 2017 in Finland. This development was accompanied by decreasing 1-year mortality and the reduction of the ischaemic stroke rate by more than half, particularly among elderly patients, whereas there was only slight increase in severe bleeding events.

Low socioeconomic status has been associated with poor outcomes in patients with atrial fibrillation (AF). However, little is known about socioeconomic disparities in adherence to stroke prevention with direct oral anticoagulants (DOACs). We assessed the hypothesis that AF patients with higher income or educational levels have better adherence to DOACs in terms of treatment implementation and persistence. The used nationwide registry‐based FinACAF cohort covers all patients with incident AF starting DOACs in Finland during 2011–2018. The implementation analyses included 74 222 (mean age 72.7 ± 10.5 years, 50.8% female) patients, and persistence analyses included 67 503 (mean age 75.3 ± 8.9 years, 53.6% female) patients with indication for permanent anticoagulation (CHA ₂ DS ₂ ‐VASc score >1 in men and >2 in women). Patients were divided into income quartiles and into three categories based on their educational attainment. Therapy implementation was measured using the medication possession ratio (MPR), and patients with MPR ≥0.90 were defined adherent. Persistence was measured as the incidence of therapy discontinuation, defined as the first 135‐day period without DOAC purchases after drug initiation. Patients with higher income or education were consistently more likely adherent to DOACs in the implementation phase (comparing the highest income or educational category to the lowest: adjusted odds ratios 1.18 (1.12–1.25) and 1.21 (1.15–1.27), respectively). No association with income or educational levels was observed on the incidence of therapy discontinuation. In conclusion, we observed that income and educational levels both have independent positive association on the implementation of DOAC therapy but no association on therapy persistence in patients with AF.

Aims: To investigate sex‐specific temporal trends in the initiation of oral anticoagulant (OAC) therapy among patients diagnosed with atrial fibrillation (AF) in Finland between 2007 and 2018.Methods: The registry‐linkage Finnish AntiCoagulation in Atrial Fibrillation (FinACAF) Study included all patients with incident AF in Finland from 2007 to 2018. The primary outcome was the initiation of any OAC therapy.Results: We identified 229,565 patients with new‐onset AF (50.0% women; mean age 72.7 years). The initiation of OAC therapy increased continuously during the observation period. While women were more likely to receive OAC therapy overall, after adjusting for age, stroke risk factors and other confounding factors, female sex was associated with a marginally lower initiation of OACs (unadjusted and adjusted hazard ratios comparing women to men: 1.08 (1.07–1.10) and 0.97 (0.96–0.98), respectively). Importantly, the gender disparities in OAC use attenuated and reached parity by the end of the observation period. Furthermore, when only patients eligible for OAC therapy according to the contemporary guidelines were included in the analyses, the gender inequalities in OAC initiation appeared minimal. Implementation of direct OACs for stroke prevention was slightly slower among women.Conclusion: This nationwide retrospective cohort study covering all patients with incident AF in Finland from 2007 to 2018 observed that although female sex was initially associated with a lower initiation of OAC therapy, the sex‐related disparities resolved over the course of the study period.