Highlights
- •1/3 of patients with atrial fibrillation had poor adherence to oral anticoagulants.
- •Good adherence to oral anticoagulants was related to less adverse events.
- •Acenocoumarol was associated with more adverse events than direct oral anticoagulants.
Abstract
Objectives
To explore the implications of adherence to oral anticoagulants (OACs) on all-cause
mortality and cardiovascular outcomes in patients with atrial fibrillation (AF).
Methods
This post-hoc analysis of the MISOAC-AF trial included recently hospitalized patients
with AF. Adherence to OACs was assessed by the proportion of days covered (PDC). Good
adherence was defined as PDC >80 %. Cox regression models were used to associate PDC
with clinical outcomes of all-cause death, cardiovascular death (CVD), stroke, and
bleeding. A sub-analysis was performed among adherent patients to compare outcomes
between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs).
Results
During a median 31-month follow-up, 778 cardiac patients with comorbid AF who had
been prescribed OACs upon hospital discharge were studied. The mean PDC was 0.78;
66 % of patients had good adherence (>80 %) which was associated with lower risk of
all-cause death [adjusted hazard ratio (aHR): 0.64; 95 % confidence interval (CI):
0.46 to 0.84, p < 0.001] and CVD (aHR: 0.70; 95 % CI: 0.50 to 0.97, p = 0.03). The risk of stroke and major or non-major bleeding did not differ by adherence
status. Among adherent patients to OACs, VKA use was associated with higher rates
of all-cause death (p < 0.001), CVD (p < 0.001), and stroke (p = 0.01); no differences were found regarding major or non-major bleeding risk.
Conclusions
In recently hospitalized patients with AF, good adherence to OACs was associated with
a reduced risk of all-cause death and CVD. The rates of stroke or bleeding events
were not significantly different. VKAs were associated with more adverse events compared
to DOACs.
Graphical abstract
Graphical Abstract
Keywords
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References
- 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS).in: European Heart Journal. Vol. 42. Oxford University Press, 2021: 373-498
- Multimorbidity and co-morbidity in atrial fibrillation and effects on survival: findings from UK Biobank cohort.EP Europace. 2018 Nov 1; 20 ([cited 2022 May 30]) (Available from: https://academic.oup.com/europace/article/20/FI_3/f329/4582725): f329-f336
- Real-world adherence and persistence to direct Oral anticoagulants in patients with atrial fibrillation:a systematic review and meta-analysis.Circ Cardiovasc Qual Outcomes. 2020; 13e005969
- Effectiveness and safety of DOACs vs. VKAs in AF patients with cancer: evidence from randomized clinical trials and observational studies.Front Cardiovasc Med. 2021 Nov 5; 8
- Adherence to oral anticoagulants among patients with atrial fibrillation: a systematic review and meta-analysis of observational studies.BMJ Open [Internet]. 2020 Apr 1; 10 (Available from: https://bmjopen.bmj.com/content/10/4/e034778)e034778
- Use of direct oral anticoagulants in patients with atrial fibrillation in Scotland: applying a coherent framework to drug utilisation studies.Pharmacoepidemiol Drug Saf [Internet]. 2017 Nov 1; 26 (Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/pds.4272): 1378-1386
- Primary nonadherence to oral anticoagulants in patients with atrial fibrillation: real-world data from a population-based cohort.J Manag Care Spec Pharm [Internet]. 2018 May 1; 24 (Available from: www.jmcp.org): 440-448
- Treatment and persistence with oral anticoagulants among newly diagnosed patients with non-valvular atrial fibrillation: a retrospective observational study in a US commercially insured and Medicare Advantage population.BMJ Open [Internet]. 2018 Jun 1; 8 (Available from: https://bmjopen.bmj.com/content/8/6/e020676)e020676
- Adherence to rivaroxaban versus apixaban among patients with non-valvular atrial fibrillation: analysis of overall population and subgroups of prior oral anticoagulant users.PLoS One [Internet]. 2018 Apr 1; 13 (Available from: /pmc/articles/PMC5886396/)
- Dabigatran persistence and adherence in New Zealand: a nationwide retrospective observational study.BMJ Open [Internet]. 2018 Apr 1; 8 (Available from: https://bmjopen.bmj.com/content/8/4/e020212)e020212
- Adherence to anticoagulant treatment with apixaban and rivaroxaban in a real-world setting.Clin Trials Regul Sci Cardiol. 2016 Jun; 1: 1-4
- Rationale and design of a randomized study comparing Motivational Interviewing to Support Oral Anticoagulation adherence versus usual care in patients with nonvalvular atrial fibrillation: The MISOAC-AF trial [Internet].in: Hellenic Journal of Cardiology. Vol. 61. Hellenic Cardiological Society, 2020: 453-454 (Available from: https://pubmed.ncbi.nlm.nih.gov/32259588/)
- Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with non-valvular Atrial Fibrillation (MISOAC-AF): a randomized clinical trial.Eur Heart J Cardiovasc Pharmacother [Internet]. 2021 Apr 9; 7 (Available from: https://academic.oup.com/ehjcvp/article/7/FI1/f63/5825732): f63-f71
Nau DP. Proportion of Days Covered (PDC) as a Preferred Method of Measuring Medication Adherence.
- Adherence measures.([Internet]. Available from)
- Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients.J Thromb Haemost [Internet]. 2005 Apr 1; 3 (Available from https://onlinelibrary.wiley.com/doi/full/10.1111/j.1538-7836.2005.01204.x): 692-694
- Multimorbidity and the risk of hospitalization and death in atrial fibrillation: a population-based study.Am Heart J [Internet]. 2017 Mar; 1 (Available from https://pubmed.ncbi.nlm.nih.gov/28267478/): 74-84
- Mortality outcomes in patients receiving direct oral anticoagulants: a systematic review and meta-analysis of randomized controlled trials.J Thromb Haemost [Internet]. 2015 Nov 1; 13 (Available from https://pubmed.ncbi.nlm.nih.gov/26356595/): 2012-2020
- Adherence to anticoagulation and risk of stroke among Medicare beneficiaries newly diagnosed with atrial fibrillation.Am J Cardiovasc Drugs [Internet]. 2020 Apr 1; 20 (Available from https://pubmed.ncbi.nlm.nih.gov/31523759/): 199-207
- Adherence to oral anticoagulation in ischemic stroke patients with atrial fibrillation.Ann Med [Internet]. 2021; 53 (Available from https://www.tandfonline.com/doi/abs/10.1080/07853890.2021.1968031): 1613-1620
- All-cause mortality and cardiovascular outcomes with non-vitamin K oral anticoagulants versus warfarin in patients with heart failure in the Food and Drug Administration adverse event reporting system.Am J Ther [Internet]. 2019; 26 (Available from https://pubmed.ncbi.nlm.nih.gov/31145139/): e671-e678
- Original research article: mortality and oral anticoagulants in the Food and Drug Administration Adverse Event Reporting System.Open Heart [Internet]. 2017 Jun 1; 4 (Available from: /pmc/articles/PMC5515169/)
- Identification and weighting of the most critical “real-life” drug-drug interactions with acenocoumarol in a tertiary care hospital.Eur J Clin Pharmacol [Internet]. 2013 Mar; 69 (Available from https://pubmed.ncbi.nlm.nih.gov/22903542/): 617-627
- Estimating the effect of medication adherence on health outcomes among patients with type 2 diabetes-an application of marginal structural models.Value Health. 2010; 13: 1038-1045
- Medication taking behaviors in patients taking warfarin versus direct oral anticoagulants: a systematic review.Expert Rev Cardiovasc Ther. 2019 Jun 3; 17: 427-434
- Factors associated with anticoagulation adherence in Chinese patients with non-valvular atrial fibrillation.Patient Prefer Adherence [Internet]. 2021 Mar; 1 (Available from https://www.dovepress.com/factors-associated-with-anticoagulation-adherence-in-chinese-patients–peer-reviewed-fulltext-article-PPA): 493-500
- Medication adherence influencing factors - an (updated) overview of systematic reviews.Syst Rev [Internet]. 2019 May 10; 8 (Available from https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-019-1014-8): 1-17
- A smartphone app to improve oral anticoagulation adherence in patients with atrial fibrillation: prospective observational study.JMIR Mhealth Uhealth [Internet]. 2022 Jan 1; 10 (Available from: /pmc/articles/PMC8783280/)
- Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation.Eur Heart J Suppl [Internet]. 2022 Feb 16; 16;24 (Available from: https://academic.oup.com/eurheartjsupp/article/24/Supplement_A/A42/6529571): A42-A55
Article info
Publication history
Published online: October 10, 2022
Accepted:
September 5,
2022
Received in revised form:
August 31,
2022
Received:
August 1,
2022
Identification
Copyright
© 2022 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved. All rights reserved.
