Sex differences in treatment strategy and adverse outcomes among patients 75 and older with atrial fibrillation in the MarketScan database

Vinita Subramanya, J’Neka N.S. Claxton, Pamela L. Lutsey, Richard F. MacLehose, Lin Y. Chen, Alanna M. Chamberlain, Faye L. Norby, Alvaro Alonso

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4 Scopus citations


Background: Women with atrial fibrillation (AF) experience greater symptomatology, worse quality of life, and have a higher risk of stroke as compared to men, but are less likely to receive rhythm control treatment. Whether these differences exist in elderly patients with AF, and whether sex modifies the effectiveness of rhythm versus rate control therapy has not been assessed. Methods: We studied 135,850 men and 139,767 women aged ≥ 75 years diagnosed with AF in the MarketScan Medicare database between 2007 and 2015. Anticoagulant use was defined as use of warfarin or a direct oral anticoagulant. Rate control was defined as use of rate control medication or atrioventricular node ablation. Rhythm control was defined by use of anti-arrhythmic medication, catheter ablation or cardioversion. We used multivariable Poisson and Cox regression models to estimate the association of sex with treatment strategy and to determine whether the association of treatment strategy with adverse outcomes (bleeding, heart failure and stroke) differed by sex. Results: At the time of AF, women were on average (SD) 83.8 (5.6) years old and men 82.5 (5.2) years, respectively. Compared to men, women were less likely to receive an anticoagulant or rhythm control treatment. Rhythm control (vs. rate) was associated with a greater risk for heart failure with a significantly stronger association in women (HR women = 1.41, 95% CI 1.34–1.49; HR men = 1.21, 95% CI 1.15–1.28, p < 0.0001 for interaction). No sex differences were observed for the association of treatment strategy with the risk of bleeding or stroke. Conclusion: Sex differences exist in the treatment of AF among patients aged 75 years and older. Women are less likely to receive an anticoagulant and rhythm control treatment. Women were also at a greater risk of experiencing heart failure as compared to men, when treated with rhythm control strategies for AF. Efforts are needed to enhance use AF therapies among women. Future studies will need to delve into the mechanisms underlying these differences.

Original languageEnglish (US)
Article number598
JournalBMC Cardiovascular Disorders
Issue number1
StatePublished - Dec 2021

Bibliographical note

Funding Information:
Research reported in this publication was supported by the National Institutes of Health under Award Numbers R21AG058445, K24HL148521, and R01HL122200, and by American Heart Association grant 16EIA2641001 (Alonso). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funder had no role in the design of the study; the analysis and interpretation of the data; preparation or review of the manuscript and, decision to submit for publication.

Publisher Copyright:
© 2021, The Author(s).


  • Anticoagulation
  • Atrial fibrillation
  • Heat failure
  • Major bleeding
  • Rate control
  • Rhythm control
  • Sex differences
  • Stroke


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