Atrial fibrillation (AF) is the most common heart rhythm disorder and is associated with considerable morbidity from ischemic stroke, particularly among older adults.¹ Oral anticoagulant (OAC) therapy greatly reduces stroke risk. Despite the evidence against antiplatelet use for stroke prevention, these therapies are often prescribed for AF. However, few have characterized this potentially inappropriate use in older adults.

In this issue of JAMA Internal Medicine, Ko and colleagues² examined antiplatelet use among nursing home residents with AF. The authors identified 4786 residents with AF and found that nearly a third received antiplatelet therapy only. Among these, most had no clinical indication for such therapy. Furthermore, individuals with dementia and moderate to severe cognitive impairment were more likely to use antiplatelets.

Ko et al² extend on the literature describing potentially inappropriate prescribing among individuals with AF by focusing on antiplatelet use in nursing home residents at risk. Their observation that more than 50% of individuals who received antiplatelet therapy had no indication is striking and suggests an urgent need to identify barriers to effective deprescribing and to develop and disseminate interventions that reduce the prescribing of inappropriate antiplatelet therapy in older adults with AF. Deprescribing is the process of identifying and discontinuing drugs where potential harms outweigh potential benefits, considering the patient’s medical status, level of functioning, values, and preferences.³

To date, few studies have examined deprescribing in patients with AF. One multicenter Italian study of 1578 hospitalized older adults with AF found that those with cognitive or functional impairment and a higher risk or history of bleeding were more likely to have OACs deprescribed.⁴ Deprescribing OACs was not associated with a higher risk of downstream stroke or systemic embolism. Other studies have examined deprescribing of cardiovascular medications in older adults with low cardiovascular risk or with limited life expectancies but, to date and to our knowledge, have not focused on equity.

Optimizing medical therapy is important to achieve health equity because it ensures that all patients receive regimens that are safe, effective, and tailored to their needs, particularly in populations who are often disproportionately affected by medication-related complications. Whereas prior research in AF has primarily focused on underuse of anticoagulation in racial and ethnic minoritized groups and older adults, including those with cognitive impairment, there is little research on deprescribing in these populations.⁵ Beyond AF, little is known of both inequities in and barriers to deprescribing in historically underserved populations. Some have pointed to an association between potentially inappropriate medication use and financial strain, lack of continuity of care, and lack of access to primary care in underserved minority older adults, providing some evidence for the causes of inappropriate prescribing.⁶ Yet, a deeper understanding of how to effectively reduce inappropriate medications in these populations is needed. This evidence gap represents an opportunity to advance research in what we refer to as deprescribing equity.

To achieve deprescribing equity, we must broaden beyond the traditional deprescribing framework of individual patient characteristics, prescriber behaviors, and health system–related barriers.³ A new framework includes, first, funding more research on the relationship between the health care team (eg, nurses, pharmacists, community health workers, physicians) and patients to understand how to best to communicate the need for deprescribing medications to those who have historically lacked access to medication therapies. This goal requires sufficient time to thoughtfully ensure that patients do not perceive that clinicians are giving up on care. Furthermore, this goal cannot be achieved without meaningful care partner engagement, particularly for those with cognitive impairment. Second, a deprescribing equity framework must address social determinants that are often not captured in the medical record, including establishment of trust between patients, care partners, and the care team, which must be repaired in communities who have been historically excluded from, discriminated against, or harmed by the medical establishment. Additionally, discussions about deprescribing require careful consideration when language and literacy barriers are present to ensure that medication changes are thoroughly communicated. This factor is particularly important when determining how to prioritize the competing challenges of avoiding undertreatment and overtreatment, both of which were observed by Ko and colleagues.² Finally, a deprescribing equity framework requires an assessment of the structural and environmental factors within which patients reside, as careful follow-up is key to deprescribing and may be limited for patients residing in medically underserved areas or with poor access to specialists, including geriatricians and pharmacists.⁷

Ensuring appropriate care for older adults with AF is a public health imperative. Beyond AF, eliminating polypharmacy to reduce adverse events and high pharmaceutical costs for patients and their families is an important health equity goal. Ko et al² provide new data highlighting the importance of deprescribing inappropriate antiplatelet therapy in the AF patient population. Their findings have important equity implications, as prior work has demonstrated wide racial disparities in nursing home quality.⁸ Understanding deprescribing barriers for antiplatelet therapy in AF will inform future interventions to equitably reduce the risk of stroke—and the risks of inappropriate medications—for all patients with AF.

Corresponding Author: Utibe R. Essien, MD, MPH, Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, 1100 Glendon Ave, Ste 850, Los Angeles, CA 90024 (uessien@mednet.ucla.edu).

Published Online: August 12, 2024. doi:10.1001/jamainternmed.2024.3824

Conflict of Interest Disclosures: Dr Essien reported grants from the US Department of Veterans Affairs (CDA-20-049) and the American Heart Association (Harold Amos Faculty Development Program Award). Dr Keller reported receiving research funding from the National Institutes of Health and the American Heart Association, as well as serving as a scientific adviser for Evidium, an AI-diagnostic decision support company.