Internal Medicine Resident McGill University Montréal, Nova Scotia, Canada
Background: Atrial fibrillation is the most common cardiac arrhythmia worldwide and a major contributor to ischemic stroke. Oral anticoagulant (OAC) use is critical for stroke prevention, yet racial and ethnic disparities persist. We aimed to determine if ethno-racial disparities exist in prescriptions of guideline-based anticoagulation therapy, the quality of anticoagulation management, and differences in complication rates.
METHODS AND RESULTS: A systematic scoping review that examined racial and ethnic differences in OAC use and complications for atrial fibrillation was conducted. Six databases: CINAHL, EMBASE, OVID, SCOPUS, Web of Science, and PubMed were used to carry out the electronic search strategy and were last searched in March 2025. Race and ethnicity were reported following the Canadian Medical Association Journal (CMAJ) guidelines. Pooled odds ratios (OR) with 95% confidence interval (CI) of OAC prescription differences were calculated using aggregated meta-analyses in Stata.
2073 studies resulted from the search, of which 53 studies were included in the final review. A total of 21 studies were included in the meta-analysis examining the likelihood of OAC prescription in White versus racialized patients. Notably, 19 of the 21 studies were conducted in the United States. Across these studies, a total of 5,793,143 individuals with atrial fibrillation were considered eligible for OAC therapy, of whom 5,118,009 were identified as White. Meta-analysis displayed that White patients were more likely to receive OAC compared to racialized patients, with a pooled odds ratio of 1.35 (95% CI: 1.25-1.45, P< 0.001) (Figure 2). Qualitative data analysis revealed several common trends. Direct oral anticoagulants (DOACs) were less frequently prescribed to racialized patients, especially Black individuals, and warfarin was more commonly used in this group. Although this pattern was consistent across much of the literature, some studies reported no racial differences in prescribing patterns. Differences in INR monitoring were observed, with racialized patients spending less time within the therapeutic range. They were also more frequently prescribed inappropriate doses of OACs.
Conclusion: This scoping review highlights racial and ethnic disparities in anticoagulation therapy for atrial fibrillation. Given the limited representation of racialized populations in our study sample, these disparities may be underestimated. Future efforts should focus on understanding the underlying factors contributing to these disparities, including healthcare access, provider biases, and patient education to implement targeted interventions for equitable care. Indigenous communities, including Inuit and Cree populations, are underrepresented in this research field and should be prioritized in future studies.
