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Safari A, Helisaz H, Salmasi S, Adelakun A, De Vera MA, Andrade JG, Deyell MW, Loewen P. Association Between Oral Anticoagulant Adherence and Serious Clinical Outcomes in Patients With Atrial Fibrillation: A Long-Term Retrospective Cohort Study. J Am Heart Assoc 2024; 13:e035639. [PMID: 39248280 DOI: 10.1161/jaha.124.035639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 07/22/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Patients with atrial fibrillation are frequently nonadherent to oral anticoagulants (OACs) prescribed for stroke and systemic embolism (SSE) prevention. We quantified the relationship between OAC adherence and atrial fibrillation clinical outcomes using methods not previously applied to this problem. METHODS AND RESULTS Retrospective observational cohort study of incident cases of atrial fibrillation from population-based administrative data over 23 years. The exposure of interest was proportion of days covered during 90 days before an event or end of follow-up. Cox proportional hazard models were used to evaluate time to first SSE and the composite of SSE, transient ischemic attack, or death and several secondary outcomes. A total of 44 172 patients were included with median follow-up of 6.7 years. For direct OACs (DOACs), each 10% decrease in adherence was associated with a 14% increased hazard of SSE and 5% increased hazard of SSE, transient ischemic attack, or death. For vitamin K antagonist (VKA) the corresponding increase in SSE hazard was 3%. Receiving DOAC or VKA was associated with primary outcome hazard reduction across most the proportion of days covered spectrum. Differences between VKA and DOAC were statistically significant for all efficacy outcomes and at most adherence levels. CONCLUSIONS Even small reductions in OAC adherence in patients with atrial fibrillation were associated with significant increases in risk of stroke, with greater magnitudes for DOAC than VKA. DOAC recipients may be more vulnerable than VKA recipients to increased risk of stroke and death even with small reductions in adherence. The worsening efficacy outcomes associated with decreasing adherence occurred without the benefit of major bleeding reduction.
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Affiliation(s)
- Abdollah Safari
- School of Mathematics, Statistics, and Computer Science, College of Science University of Tehran Iran
| | - Hamed Helisaz
- Faculty of Applied Science University of British Columbia Vancouver Canada
- GranTAZ Consulting Ltd. Vancouver Canada
| | | | - Adenike Adelakun
- Health Economics and Outcomes Research GlaxoSmithKline Inc. Mississauga Canada
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences University of British Columbia Vancouver Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences University of British Columbia Vancouver Canada
| | - Jason G Andrade
- Division of Cardiology, Faculty of Medicine University of British Columbia Vancouver Canada
- Atrial Fibrillation Clinic Vancouver General Hospital Vancouver Canada
- UBC Center for Cardiovascular Innovation Vancouver Canada
- Montreal Heart Institute Université de Montréal Montréal Canada
| | - Marc W Deyell
- Division of Cardiology, Faculty of Medicine University of British Columbia Vancouver Canada
- UBC Center for Cardiovascular Innovation Vancouver Canada
- Centre for Health Evaluation & Outcome Sciences Providence Health Care Research Institute Vancouver Canada
| | - Peter Loewen
- Faculty of Pharmaceutical Sciences University of British Columbia Vancouver Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences University of British Columbia Vancouver Canada
- UBC Center for Cardiovascular Innovation Vancouver Canada
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Salmasi S, Safari A, De Vera MA, Högg T, Lynd LD, Koehoorn M, Barry AR, Andrade JG, Deyell MW, Rush KL, Zhao Y, Loewen P. Adherence to direct or vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a long-term observational study. J Thromb Thrombolysis 2024; 57:437-444. [PMID: 38103148 PMCID: PMC10961264 DOI: 10.1007/s11239-023-02921-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 12/17/2023]
Abstract
Our objectives were to measure long-term adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and to identify patient factors associated with adherence. Using linked, population-based administrative data from British Columbia, Canada, an incident cohort of adults prescribed OACs for AF was identified. We calculated the proportion of days covered (PDC) as a time-dependent covariate for each 90-day window from OAC initiation until the end of follow-up. Associations between patient attributes and adherence were assessed using generalized mixed effect linear regression models. 30,264 patients were included. Mean PDC was 0.69 (SD 0.28) over a median follow-up of 6.7 years. 54% of patients were non-adherent (PDC < 0.8). After controlling for confounders, factors positively associated with adherence were number of drug class switches, history of stroke or transient ischemic attack, history of vascular disease, time since initiation, and age. Age > 75 years at initiation, polypharmacy (among VKA users only), and receiving DOAC (vs. VKA) were negatively associated with adherence. PDC decreased over time for VKA users and increased for DOAC users. Over half of AF patients studied were, on average, nonadherent to OAC therapy and missed 32% of their doses. Several patient factors were associated with higher or lower adherence, and adherence to VKA declined during therapy while DOAC adherence increased slightly over time. To min im ize the risk stroke, adherence-supporting interventions are needed for all patients with AF, particularly those aged > 75 years, those with prior stroke or vascular disease, VKA users with polypharmacy, and DOAC recipients.
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Affiliation(s)
- Shahrzad Salmasi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Abdollah Safari
- Department of Mathematics, Statistics, and Computer Science, University of Tehran, Tehran, Iran
- Department of Data Analytics, Statistics and Informatics, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care Research Institute, Vancouver, BC, Canada
| | - Tanja Högg
- Department of Statistics, University of British Columbia, Vancouver, BC, Canada
| | - Larry D Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care Research Institute, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Mieke Koehoorn
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Arden R Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Jason G Andrade
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- UBC Center for Cardiovascular Innovation, Vancouver, BC, Canada
| | - Marc W Deyell
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kathy L Rush
- School of Nursing, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Yinshan Zhao
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Peter Loewen
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver Campus, 2405 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.
- UBC Center for Cardiovascular Innovation, Vancouver, BC, Canada.
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