The atrial fibrillation (AF) market across the eight major markets (8MM) is forecast to decline at a negative compound annual growth rate (CAGR) of 3.2%, falling from $14.5 billion in 2022 to $10.5 billion in 2032, according to GlobalData. The decline is largely attributed to generic erosion of the leading novel oral anticoagulants (NOACs).

GlobalData’s report, Atrial Fibrillation: Eight Market Drug Forecast and Market Analysis – Update, identifies Boehringer Ingelheim’s Pradaxa (dabigatran), Bayer’s Xarelto (rivaroxaban), Bristol Myers Squibb’s Eliquis (apixaban), and Daiichi Sankyo’s Savaysa (edoxaban) as the main contributors to declining NOAC sales. Overall, NOAC revenue across the 8MM is projected to fall from $13.4 billion in 2022 to $7.5 billion in 2032, representing a negative CAGR of 5.6%.

“Nevertheless, part of these losses will be offset by the introduction and uptake of novel FXI/FXIa inhibitors, which are expected to launch across the 8MM throughout the forecast period 2022-32. In addition, the calcium channel blocker etripamil is anticipated to launch during the forecast period,” said Dr Shireen Mohammad, senior cardiovascular & metabolic disorders analyst at GlobalData.

GlobalData highlights four major unmet needs in AF therapy identified by key opinion leaders: safer anticoagulants with reduced bleeding risk, options for patients with severe chronic kidney disease or renal failure, safer antiarrhythmics for maintaining sinus rhythm, and effective rapid-acting cardioversion agents.

Pipeline therapies expected to address these gaps include Anthos Therapeutics’ abelacimab, BMS and Johnson & Johnson’s milvexian, and Milestone Pharmaceuticals’ etripamil. FXI/FXIa inhibitors such as abelacimab and milvexian target the FXI anticoagulation system, potentially offering hemostasis-sparing anticoagulation as a safer alternative to NOACs. Etripamil is an intranasal calcium channel blocker designed for rapid self-administration during symptomatic AF episodes, providing fast rate control with fewer hospital visits and side effects.

Dr Mohammad added: “Despite the anticipated decline in overall market value, the US will account for 72% of total global sales by 2032, due to its large patient population and sustained demand for advanced therapies. While increasing competition from generics and pricing pressures are expected to challenge growth globally, opportunities remain for innovation in device-based interventions and next-generation anticoagulants. As the market shifts, stakeholders who adapt to evolving clinical needs and competitive dynamics will be best positioned to capture long-term value.”

The report signals a significant shift in AF management over the next decade, highlighting both the pressure on existing NOACs and potential opportunities for next-generation anticoagulants and device-based interventions to address unmet clinical needs.