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Gilhofer TS, Schweiger V, Gehler M, Bokemeyer V, Chen M, Candreva A, Würdinger M, Di Vece D, Templin C, Niederseer D, Stähli BE, Stehli J, Gotschy A, Jakob P, Ruschitzka F, Binder R, Nietlispach F, Michel J, Kasel AM. Long-term outcomes after echocardiography versus fluoroscopy-guided left atrial appendage closure: Is there still a role for a simplified approach? Catheter Cardiovasc Interv 2024; 104:343-355. [PMID: 39031623 DOI: 10.1002/ccd.31126] [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: 11/20/2023] [Revised: 05/10/2024] [Accepted: 06/09/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) represents an alternative to oral anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation (AF). While transoesophageal echocardiography is the current standard for guiding LAAC procedures, several centers have employed fluoroscopic guidance alone. However, data on long-term outcomes are lacking. METHODS A total of 536 patients with AF undergoing LAAC and with available data on long-term follow-up were included in the retrospective, single-center analysis. Outcomes of patients undergoing fluoroscopy-guided LAAC were compared with those undergoing echocardiography guided LAAC. Time-dependent analysis was performed with the Kaplan-Meier method. RESULTS A total of 234 (44%) and 302 (56%) patients were treated with echocardiography and fluoroscopy guidance, respectively. Baseline characteristics did not differ between the two groups. Procedural success rates were high in both groups (97% of fluoroscopy vs. 98% of echocardiography guided procedures; p = 0.92) and rates of relevant peri-device leaks (p = 0.50) and device-related thrombus formation (p = 0.22) did not differ between groups. Median clinical follow-up time was 48 (IQR 19-73) months. Rates of all-cause mortality (p = 0.15, HR 0.83, CI 0.64-1.07) and stroke (p = 0.076, HR 2.23, CI 0.90-5.54) were comparable among groups. CONCLUSION LAAC with fluoroscopy guidance alone is equally safe and leads to similar clinical outcome compared to LAAC with additional echocardiography guidance.
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Affiliation(s)
- Thomas S Gilhofer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Victor Schweiger
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Mario Gehler
- Department of Cardiology, Hospital St. Gallen, St. Gallen, Switzerland
| | - Victoria Bokemeyer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Mi Chen
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Alessandro Candreva
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Michael Würdinger
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Davide Di Vece
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - David Niederseer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Barbara E Stähli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Julia Stehli
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Alexander Gotschy
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
- Institute for Biomedical Engineering, University and ETH Zurich, Zürich ETH-Zentrum, Zurich, Switzerland
| | - Philipp Jakob
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - Ronald Binder
- Department of Internal Medicine, Hospital Wels-Grieskirchen, Wels, Austria
| | | | - Jonathan Michel
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
| | - A Markus Kasel
- Department of Cardiology, University Heart Center, University Hospital Zurich, Switzerland
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2
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Kamath CC, Espinoza Suarez NR, Vallejo S, Montori VM, Brito JP, Boehmer KR. Not all cost conversations are the same: An exploration of potential value in cost conversations during Atrial fibrillation treatment decision making. PATIENT EDUCATION AND COUNSELING 2024; 128:108366. [PMID: 39032442 DOI: 10.1016/j.pec.2024.108366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES To explore the cost conversations taking place when patients with atrial fibrillation and their clinicians decide on whether and how to use anticoagulation to prevent strokes. METHODS Secondary qualitative thematic analysis of conversations from 476 clinical encounters in three sites of a multicenter randomized trial comparing usual care with and without a shared decision-making tool. RESULTS We identified three themes with subthemes: (1) What was discussed: conversation content (2) How content was transmitted: communication patterns and (3) Implicit conversation drivers. Due to each patient's unique circumstances, bi-directional conversations focused on relationship- and solution-based content enabled better cost burden discovery. Conversation drivers included affordability, comorbidities, preferences, and uncertainty about future costs. CONCLUSIONS Cost conversations were often initiated by clinicians, and if they did not invite a response, patients passively received information without understanding or weighing cost burden. When clinicians discussed cost information using relational or solution-focused content and bi-directional communication patients were more likely to engage in discussion including their unique situation. PRACTICE IMPLICATIONS Solution-focused cost conversations can reduce financial treatment burden, but require estimates of out-of-pocket costs, insurance coverage, and long-term financial effects of various options. Conversation tools and information on financial resources are valuable to patients and clinicians.
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Affiliation(s)
- Celia C Kamath
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA; Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Nataly R Espinoza Suarez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; VITAM - Center for Sustainable Health Research, Integrated University Health and Social Services Center of Capitale-Nationale, Quebec City, QC, Canada; Faculty of Nursing, Laval University, Quebec City, QC, Canada
| | | | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Juan P Brito
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Endocrinology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kasey R Boehmer
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA; Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Health Care Delivery Research, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, MN, USA.
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Goodman SG, Roy D, Pollack CV, Leblanc K, Kwaku KF, Barnes GD, Bonaca MP, True Hills M, Campello E, Fanikos J, Connors JM, Weitz JI. Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics. Crit Pathw Cardiol 2024; 23:47-57. [PMID: 38381695 PMCID: PMC11191052 DOI: 10.1097/hpc.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.
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Affiliation(s)
- Shaun G. Goodman
- From the Division of Cardiology, St Michael’s Hospital, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
- Canadian VIGOUR Centre and Division of Cardiology, University of Alberta, Edmonton, AB, Canada
| | - Denis Roy
- Department of Medicine and Research Center, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Charles V. Pollack
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Kori Leblanc
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Kevin F. Kwaku
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Geoffrey D. Barnes
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Marc P. Bonaca
- Division of Cardiology, CPC Clinical Research, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | | | - Elena Campello
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
| | - John Fanikos
- Department of Pharmacy, Brigham and Women’s Hospital
| | - Jean M. Connors
- Hematology Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey I. Weitz
- Department of Medicine, McMaster University, Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
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Sandberg EL, Halvorsen S, Berge T, Grimsmo J, Atar D, Leangen Grenne B, Jortveit J. Digital recruitment and compliance to treatment recommendations in the Norwegian Atrial Fibrillation self-screening pilot study. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2024; 5:371-378. [PMID: 38774377 PMCID: PMC11104466 DOI: 10.1093/ehjdh/ztae026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/12/2024] [Accepted: 03/28/2024] [Indexed: 05/24/2024]
Abstract
Aims Atrial fibrillation (AF) is prevalent, undiagnosed in approximately one-third of cases, and is associated with severe complications. Guidelines recommend screening individuals at increased risk of stroke. This report evaluated the digital recruitment procedure and compliance with the follow-up recommendations in participants with screen-detected AF in the Norwegian Atrial Fibrillation self-screening pilot study. Methods and results Norwegians ≥65 years were invited through Facebooks posts, web pages, and newspapers to participate in the study. Targeted Facebook posts promoted over 11 days reached 84 208 users and 10 582 visitors to the study homepage. This accounted for 51% of the total homepage visitors (n = 20 704). A total of 2118 (10%) of the homepage visitors provided digital consent to participate after they met the inclusion criteria. The mean (standard deviation) age of the participants was 70 (4) years, and the majority [n = 1569 (74%)] were women. A total of 1849 (87%) participants completed the electrocardiogram self-screening test, identifying AF in 41 (2.2%) individuals. Of these, 39 (95%) participants consulted a general practitioner, and 34 (83%) participants initiated anticoagulation therapy. Conclusion Digital recruitment and inclusion in digital AF screening with a high rate of initiation of anticoagulation therapy in AF positive screening cases are feasible. However, digital recruitment and inclusion may introduce selection bias with regard to age and gender. Larger studies are needed to determine the efficacy and cost-effectiveness of a fully digital AF screening. Trial registration Clinical trials: NCT04700865.
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Affiliation(s)
- Edvard Liljedahl Sandberg
- Department of Cardiology, Sorlandet Hospital, Arendal, Sykehusveien 1, 4838 Arendal, Norway
- Institute of Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Sigrun Halvorsen
- Institute of Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
- Department of Cardiology, Oslo University Hospital Ullevaal, Kirkeveien 166, 0450 Oslo, Norway
| | - Trygve Berge
- Institute of Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
- Department of Medical Research and Department of Internal Medicine, Vestre Viken Hospital Trust, Baerum Hospital, Rud, Sogneprest Munthe-kaas vei 100, 1346 Gjettum, Norway
| | - Jostein Grimsmo
- Department of Cardiac Rehabilitation, Lovisenberg Rehabilitation, Cathinka Guldbergs Hospital, Ragnar Strøms Veg 10, 2067 Jessheim, Norway
- LHL (National Organization for Heart and Lung Diseases), Ragnar Strøms Veg 4, 5067 Jessheim, Norway
| | - Dan Atar
- Institute of Clinical Medicine, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
- Department of Cardiology, Oslo University Hospital Ullevaal, Kirkeveien 166, 0450 Oslo, Norway
| | - Bjørnar Leangen Grenne
- Clinic of Cardiology, St. Olavs Hospital, Trondheim, Prinsesse Kristinas gate 3, 7030 Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Postboks 8905, 7491 Trondheim, Norway
| | - Jarle Jortveit
- Department of Cardiology, Sorlandet Hospital, Arendal, Sykehusveien 1, 4838 Arendal, Norway
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Silva Pinto S, Henriques TS, Teixeira ASC, Monteiro H, Martins C. Appropriateness of prescribing profiles and intake adherence to non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: analysis of a retrospective longitudinal study using real-world data from Northern Portugal (AF-React Study). BMJ Open 2024; 14:e076108. [PMID: 38688672 PMCID: PMC11086444 DOI: 10.1136/bmjopen-2023-076108] [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] [Received: 05/28/2023] [Accepted: 03/04/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES This study aimed to assess the appropriateness of prescribing profiles and intake adherence to non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF). DESIGN Retrospective longitudinal study. SETTING The study was conducted in the Regional Health Administration of Northern Portugal. PARTICIPANTS The authors selected a database of 21 854 patients with prescriptions for NOACs between January 2016 and December 2018 and were classified with AF until December 2018. OUTCOME MEASURES The appropriate dosage of NOAC for patients with AF divided into three categories: contraindicated, inconsistent and consistent, based on the 2020 European Society of Cardiology guidelines for AF. RESULTS Dabigatran had a lower percentage of guideline-consistent doses (n=1657, 50.1%) than other drugs such as rivaroxaban (n=4737, 81.6%), apixaban (n=3830, 78.7%) and edoxaban (n=436, 82.1%). Most patients with an inconsistent dose were prescribed a lower dose than recommended based on their glomerular filtration rate (GFR). Among patients younger than 75 years with GFR >60 mL/min, 59.8% (n=10 028) had an adequate GFR range, while 27.8% (n=7166) of GFR measurements from patients older than 75 years old and 29.4% (n=913) of GFR measurements from patients younger than 75 years with GFR <60 mL/min were within an adequate time range. Adherence to NOACs varied across different drugs, with 59.1% (n=540) adhering to edoxaban, 56.3% (n=5443) to rivaroxaban, 55.3% (n=3143) to dabigatran and 53.3% (n=4211) to apixaban. CONCLUSIONS Dabigatran had the lowest percentage of guideline-consistent doses. Patients younger than 75 years with GFR >60 mL/min had the highest percentage with an adequate GFR range, while other groups who require closer GFR monitoring had lower percentages within an adequate GFR range. Adherence to NOACs differed among different drugs, with greater adherence to treatment with edoxaban and less adherence to apixaban.
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Affiliation(s)
- Susana Silva Pinto
- São Tomé Family Health Unit, Santo Tirso, Portugal
- CINTESIS@RISE, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences, University of Porto, Porto, Portugal
| | - Teresa S Henriques
- CINTESIS@RISE, University of Porto, Porto, Portugal
- CI-IPOP (Health Research Network), Portuguese Oncoloy Institute of Porto, Porto, Portugal
| | - Andreia Sofia Costa Teixeira
- CINTESIS@RISE, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences, University of Porto, Porto, Portugal
- ADiT-LAB, Instituto Politécnico de Viana do Castelo, Viana do Castelo, Portugal
| | - Hugo Monteiro
- Regional Health Administration of Northern Portugal, Ministry of Health, Porto, Portugal
| | - Carlos Martins
- CINTESIS@RISE, University of Porto, Porto, Portugal
- H4A Primary Health Care Research Network, Porto, Portugal
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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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Ton MT, Quang Ho TH, Nguyen VL, Pham HM, Hoang SV, Vo NT, Nguyen TQ, Pham LT, Mai TD, Nguyen TH. Selection of Non-vitamin K Antagonist Oral Anticoagulant for Stroke Prevention in Atrial Fibrillation Based on Patient Profile: Perspectives from Vietnamese Experts. Part 2. Eur Cardiol 2023; 18:e62. [PMID: 38174218 PMCID: PMC10762676 DOI: 10.15420/ecr.2023.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/18/2023] [Indexed: 01/05/2024] Open
Abstract
Part 1 of this review provided an overview of AF in Vietnam, with a particular focus on primary and secondary stroke prevention. Part 2 explores the management of AF in special, high-risk and clinically common patient populations, including those with renal impairment, diabetes, the elderly, and those with coronary artery disease. Furthermore, Part 2 addresses the challenges posed by patients with AF who have a bioprosthetic valve, a group situated in a grey area of consideration. Managing AF in these patient groups presents unique clinical challenges that require careful consideration. Physicians are tasked with addressing specific clinical questions to identify the optimal anticoagulation strategy for each individual. To inform these decisions, subgroup analyses from pivotal studies are presented alongside real-world data derived from clinical practice. By synthesising available information and considering the nuanced clinical context, the aim is to provide informed perspectives that align with current medical knowledge and contribute to the enhancement of patient care in these challenging scenarios.
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Affiliation(s)
| | | | | | - Hung Manh Pham
- Vietnam Heart Institute, Bach Mai HospitalHanoi, Vietnam
- Hanoi Medical UniversityHanoi, Vietnam
| | - Sy Van Hoang
- Cardiovascular Department, Cho Ray HospitalHo Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh CityHo Chi Minh City, Vietnam
| | - Nhan Thanh Vo
- Cardiovascular Department, Cho Ray HospitalHo Chi Minh City, Vietnam
- Cardiovascular Center, Vinmec HospitalHo Chi Minh City, Vietnam
| | | | - Linh Tran Pham
- Vietnam Heart Institute, Bach Mai HospitalHanoi, Vietnam
| | - Ton Duy Mai
- Hanoi Medical UniversityHanoi, Vietnam
- Stroke Center, Bach Mai HospitalHanoi, Vietnam
- VNU-University of Medicine and PharmacyHanoi, Vietnam
| | - Thang Huy Nguyen
- Cerebrovascular Disease Department, People's 115 Hospital
- Pham Ngoc Thach University of MedicineHo Chi Minh City, Vietnam
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Knaepen L, Delesie M, Vijgen J, Dendale P, Ector J, Desteghe L, Heidbuchel H. Adherence to oral anticoagulation measured by electronic monitoring in a Belgian atrial fibrillation population. Clin Res Cardiol 2023; 112:1812-1823. [PMID: 37498363 PMCID: PMC10698080 DOI: 10.1007/s00392-023-02261-w] [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] [Received: 04/11/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Stroke prevention using oral anticoagulation (OAC) is the first management priority in atrial fibrillation (AF). Despite the importance of good therapy adherence, real-world adherence is still suboptimal. Patient education and adherence monitoring with new technologies are recommended. The main purpose of this sub-analysis of the AF-EduCare trial was to evaluate the effect of personalized follow-up strategies on adherence to OAC. METHODS Regimen adherence was monitored by the electronic Medication Event Monitoring System cap at the start of the trial (M1) and after 12 months (M2), each for three months. Patients were part of one of three education groups (In-person, Online or App-based) or the standard care (SC) group. All are qualified for OAC therapy. RESULTS A total of 768 patients were evaluated (11.8% SC vs. 86.8% any education group, mean age: 70.1 ± 7.9 years). Patients were taking non-vitamin K OAC (once daily 53.8%; twice daily 35.9%) or vitamin K antagonists (9.4%), equally distributed over the different study arms (p = 0.457). Mean therapy adherence was high (M1:93.8 ± 10.8%; M2:94.1 ± 10.1%). During both monitoring periods, the education group scored significantly higher than SC (M1:94.2 ± 10.0% vs. 91.3 ± 15.0%; p = 0.027; M2:94.4 ± 9.3% vs. 91.6 ± 14.0%; p = 0.006). More patients in the In-person and Online groups were able to keep or improve their adherence to > 90% compared to the SC. CONCLUSION Overall adherence to OAC in all study groups, even in SC, was very high, without attrition over time. Nevertheless, targeted education led to a small but significantly improved adherence compared to SC.
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Affiliation(s)
- Lieselotte Knaepen
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium.
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium.
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium.
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium.
| | - Michiel Delesie
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
| | - Johan Vijgen
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Paul Dendale
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Joris Ector
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Lien Desteghe
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
- Heart Center Hasselt, Jessa Hospital, Stadsomvaart 11, 3500, Hasselt, Belgium
| | - Hein Heidbuchel
- Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
- Research Group Cardiovascular Diseases, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Faculty of Medicine and Life Sciences/LCRC, Hasselt University, Martelarenlaan 42, 3500, Hasselt, Belgium
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Dix C, Bortz H, da Gama M, Treloar M, Reynolds M, Ramanan R, Day T, Tran H. Adherence and persistence to direct factor Xa inhibitors in the community following newly diagnosed venous thromboembolism: a retrospective pharmacy-linkage study. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2023; 31:528-533. [PMID: 37494677 DOI: 10.1093/ijpp/riad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 07/13/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES To assess adherence and persistence to the direct factor Xa inhibitor oral anticoagulants in the community following newly diagnosed venous thromboembolism (VTE). METHODS We retrospectively reviewed community pharmacy dispensing data on all patients with newly diagnosed VTE who were prescribed direct factor Xa inhibitors, apixaban or rivaroxaban, between January 2018 and December 2019 at our institution. Proportion of days covered (PDC) was used to assess adherence at 90 days, and 6- and 12 months. Persistence was measured by participants having both dispensed supply of a factor Xa inhibitor at the end of the treatment period and no significant gaps (maximum of 60 days) in supply. KEY FINDINGS There were 225 patients identified. Overall PDC at 90 days, 6- and 12 months were 84.6%, 86.2% and 86.1%, respectively. Apixaban had a higher mean overall PDC than rivaroxaban (86.2% and 80.6%, respectively). Females demonstrated higher PDC compared with males (87.3% versus 81.2%). Overall, 133 patients (64%) were persistent with therapy. CONCLUSIONS In patients with newly diagnosed VTE treated with a factor Xa inhibitor, adherence rates are high at >80%, with females and those prescribed apixaban exhibiting higher adherence. These findings may assist clinicians in identifying those patients with VTE at risk of poor adherence.
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Affiliation(s)
- Caroline Dix
- Department of Clinical Haematology, Alfred Health, Melbourne, Victoria, Australia
| | - Hadley Bortz
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | | | | | | | - Radha Ramanan
- Department of Clinical Haematology, Alfred Health, Melbourne, Victoria, Australia
| | - Thomas Day
- Department of Haematology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Huyen Tran
- Department of Clinical Haematology, Alfred Health, Melbourne, Victoria, Australia
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10
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Lucà F, Oliva F, Abrignani MG, Di Fusco SA, Parrini I, Canale ML, Giubilato S, Cornara S, Nesti M, Rao CM, Pozzi A, Binaghi G, Maloberti A, Ceravolo R, Bisceglia I, Rossini R, Temporelli PL, Amico AF, Calvanese R, Gelsomino S, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios. J Clin Med 2023; 12:5955. [PMID: 37762897 PMCID: PMC10531873 DOI: 10.3390/jcm12185955] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | | | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | - Iris Parrini
- Cardiology Department, Ospedale Mauriziano, 10128 Turin, Italy
| | - Maria Laura Canale
- Cardiology Department, Nuovo Ospedale Versilia Lido di Camaiore Lucca, 55049 Camaiore, Italy
| | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy
| | - Giulio Binaghi
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09047 Cagliari, Italy
| | - Alessandro Maloberti
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 88046 Lamezia, Italy
| | - Irma Bisceglia
- Integrated Cardiology Services, Department of Cardio-Thoracic-Vascular, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy
| | - Roberta Rossini
- Cardiology Unit, Ospedale Santa Croce e Carle, 12100 Cuneo, Italy;
| | - Pier Luigi Temporelli
- Division of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, 28010 Gattico-Veruno, Italy
| | | | | | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
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11
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Caliandro P, Cancelloni V, Marco M, Reale G, Zauli A, Agnelli G, Caso V, Becattini C, Calabresi P, Giulia Mosconi M, Giustozzi M, Tsivgoulis G, Julian Seiffge D, Engelter ST, Lyrer P, Polymeris AA, Dittrich T, Zietz A, Marco De Marchis G, Putaala J, Strbian D, Tomppo L, Michel P, Strambo D, Salerno A, Remillard S, Buehrer M, Bavaud O, Vanacker P, Zuurbier S, Yperzeele L, Loos CM, Cappellari M, Emiliani A, Zedde M, Abdul-Rahim A, Dawson J, Cronshaw R, Schirinzi E, Del Sette M, Stretz C, Kala N, Reznik M, Schomer A, Mac Grory B, Jayaraman M, McTaggart R, Yaghi S, Furie KL, Masotti L, Grifoni E, Toni D, Risitano A, Falcou A, Petraglia L, Maria Lotti E, Padroni M, Pavolucci L, Lochner P, Silvestrelli G, Ciccone A, Alberti A, Venti M, Leone De Magistris I, Kargiotis O, Rocco A, Diomedi M, Marcheselli S, Antonenko K, Rota E, Tassinari T, Saia V, Palmerini F, Aridon P, Arnao V, Monaco S, Cottone S, Baldi A, D’Amore C, Ageno W, Pegoraro S, Ntaios G, Sagris D, Giannopoulos S, Kosmidou M, Ntais E, Romoli M, Pantoni L, Rosa S, Bertora P, Chiti A, Canavero I, Emanuele Saggese C, Plocco M, Giorli E, Palaiodimou L, Bakola E, Bandini F, Gasparro A, Terruso V, Mannino M, Pezzini A, Ornello R, Sacco S, Popovic N, Scoditti U, Genovese A, Denti L, Flomin Y, Mancuso M, Ferrari E, Chiara Caselli M, Ulivi L, Giannini N, Vadikolias K, Liantinioti C, Chondrogianni M, Halvatsiotis P, Carletti M, Karagkiozi E, Athanasakis G, Makaritsis K, Lanari A, Tatlisumak T, Acciarresi M, Vannucchi V, Lorenzini G, Tassi R, Guideri F, Acampa M, Martini G, Sohn SI, Mumoli N, Tadi P, Letteri F, Maccarrone M, Poli L, Magoni M, Galati F, Tiseo C, Gourbali V, Orlandi G, Giuntini M, Corea F, Bellesini M, Girardi L, Maimone Baronello M, Karapanayiotides T, Rueckert C, Csiba L, Szabó L, Rigatelli A, Imberti D, Zabzuni D, Pieroni A, Barlinn K, Pallesen LP, Barlinn J, Doronin B, Volodina V, Deleu D, Bonetti B, Porta C, Gentile L, Eskandari A, Paciaroni M. Risk of recurrent stroke in patients with atrial fibrillation treated with oral anticoagulants alone or in combination with anti-platelet therapy. Eur Stroke J 2023; 8:722-730. [PMID: 37458099 PMCID: PMC10472945 DOI: 10.1177/23969873231183211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Ischaemic stroke patients with atrial fibrillation (AF) are at high risk of stroke recurrence despite oral anticoagulation therapy. Patients with cardiovascular comorbidities may take both antiplatelet and oral anticoagulation therapy (OAC/AP). Our study aims to evaluate the safety and efficacy of OAC/AP therapy as secondary prevention in people with AF and ischaemic stroke. PATIENTS AND METHODS We performed a post-hoc analysis of pooled individual data from multicenter prospective cohort studies and compared outcomes in the OAC/AP cohort and patients on DOAC/VKA anticoagulation alone (OAC cohort). Primary outcome was a composite of ischaemic stroke, systemic embolism, intracranial bleeding, and major extracranial bleeding, while secondary outcomes were ischaemic and haemorrhagic events considered separately. A multivariable logistic regression analysis was performed to identify independent predictors for outcome events. To compare the risk of outcome events between the two cohorts, the relation between the survival function and the set of explanatory variables were calculated by Cox proportional hazard models and the results were reported as adjusted hazard ratios (HR). Finally another analysis was performed to compare the overall risk of outcome events in both OAC/AP and OAC cohorts after propensity score matching (PSM). RESULTS During a mean follow-up time of 7.5 ± 9.1 months (median follow-up time 3.5 months, interquartile range ±3), 2284 stroke patients were on oral anticoagulants and 215 were on combined therapy. The multivariable model demonstrated that the composite outcome is associated with age (OR: 1.03, 95% CI: 1.01-1.04 for each year increase) and concomitant antiplatelet therapy (OR: 2.2, 95% CI: 1.48-3.27), the ischaemic outcome with congestive heart failure (OR: 1.55, 95% CI: 1.02-2.36) and concomitant antiplatelet therapy (OR: 1.93, 95% CI: 1.19-3.13) and the haemorrhagic outcome with age (OR: 1.03, 95% CI: 1.01-1.06 for each year increase), alcoholism (OR: 2.15, 95% CI: 1.06-4.39) and concomitant antiplatelet therapy (OR: 2.22, 95% CI: 1.23-4.02). Cox regression demonstrated a higher rate of the composite outcome (hazard ratio of 1.93 [95% CI, 1.35-2.76]), ischaemic events (HR: 2.05 [95% CI: 1.45-2.87]) and bleeding outcomes (HR: 1.90 [95% CI, 1.06-3.40]) in OAC/AP cohort. After PSM analysis, the composite outcome remained more frequent in people treated with OAC + AP (RR: 1.70 [95% CI, 1.05-2.74]). DISCUSSION Secondary prevention with combination of oral anticoagulant and antiplatelet therapy after ischaemic stroke was associated with worse outcomes in our cohort. CONCLUSION Further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischaemic stroke in patients with atrial fibrillation.
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12
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van der Horst SFB, de Vries TA, Chu G, Bavalia R, Xiong H, van de Wiel KM, Mulder K, van Ballegooijen H, de Groot JR, Middeldorp S, Klok FA, Hemels ME, Huisman MV. Prevalence and Predictors of Nonadherence to Direct Oral Anticoagulant Treatment in Patients with Atrial Fibrillation. TH OPEN 2023; 7:e270-e279. [PMID: 37772087 PMCID: PMC10533218 DOI: 10.1055/a-2161-0928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/25/2023] [Indexed: 09/30/2023] Open
Abstract
Background For most patients with newly diagnosed atrial fibrillation (AF), direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists. However, there is concern that the lack of monitoring may impair therapy adherence and therefore the anticoagulant effect. Objective To assess 1-year DOAC nonadherence in patients with AF and a treatment indication of at least 1 year in the Dutch health care setting, and to identify predictors of nonadherence. Methods We performed a near-nationwide historical cohort study in patients with a novel DOAC indication for AF. Data were obtained from a pharmacy database, covering 65% of all outpatient prescriptions dispensed in the Netherlands. The 1-year nonadherence was assessed by the proportion of days covered; the threshold was set at <80%. Robust Poisson regression analyses were performed to identify predictors of nonadherence. Results A total of 46,211 patients were included and the 1-year nonadherence was 6.5%. We identified male sex (risk ratio [RR] 1.23, 95% confidence interval [CI]: 1.15-1.33), younger age (age ≥60 to <70 years: RR: 1.15, 95% CI: 1.00-1.33, age <60 years: RR: 2.22, 95% CI: 1.92-2.57; reference age ≥85 years), a reduced DOAC dose (RR: 1.10, 95% CI: 1.00-1.22), a twice-daily dosing regimen (RR: 1.21, 95% CI: 1.12-1.30), and treatment with apixaban (RR: 1.16, 95% CI: 1.06-1.26, reference rivaroxaban) or dabigatran (RR: 1.25, 95% CI: 1.14-1.37) as independent predictors of 1-year nonadherence. Conclusion One-year nonadherence to DOACs was low yet relevant in patients with AF newly prescribed a DOAC. Understanding the predictors for nonadherence may help identify patients at risk.
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Affiliation(s)
| | - Tim A.C. de Vries
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam UMC location University of Amsterdam, Heart Center, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
- Department of Cardiology, Hospital Rijnstate, Arnhem, The Netherlands
| | - Gordon Chu
- Department of Thrombosis and Hemostasis, Leiden UMC, Leiden, The Netherlands
- Department of Internal Medicine, Alrijne Hospital, Leiden, The Netherlands
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam UMC location University of Amsterdam, The Netherlands
- GGD Amsterdam, Amsterdam, The Netherlands
| | - Helen Xiong
- IQVIA Netherlands, Amsterdam, The Netherlands
| | | | | | | | - Joris R. de Groot
- Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam UMC location University of Amsterdam, Heart Center, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, The Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden UMC, Leiden, The Netherlands
| | - Martin E.W. Hemels
- Department of Cardiology, Hospital Rijnstate, Arnhem, The Netherlands
- Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden UMC, Leiden, The Netherlands
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13
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Lee WK, Woo SI, Hyun DK, Jung SY, Kim MS, Lee J. Impact of treatment adherence on the effectiveness and safety of oral anticoagulants in patients with atrial fibrillation: a retrospective cohort study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:216-226. [PMID: 35533394 DOI: 10.1093/ehjqcco/qcac023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/24/2022] [Accepted: 05/03/2022] [Indexed: 05/17/2023]
Abstract
AIMS The impact of adherence to oral anticoagulation has not been reported in terms of absolute risk, which would enhance patients' understanding and treatment adherence. METHODS AND RESULTS This retrospective cohort study analysed data from the National Health Insurance Database of Korea, from January 2010 to December 2018, on 84 227 patients with non-valvular atrial fibrillation (NVAF). The participants were analysed according to their overall adherence to oral anticoagulants (OACs) and further divided into four groups: non-vitamin K antagonist oral anticoagulant (NOAC) adherent, vitamin K antagonist (VKA) adherent, NOAC non-adherent, and VKA non-adherent. The incidence of ischaemic stroke, major bleeding, and death was compared between the four groups using risk difference, number needed to treat and number needed to harm. Among the participants, 50 178 were adherent to (OACs), while 34 049 were non-adherent. The incidence of major bleeding was higher in the adherent group (4.49%; 95% confidence interval, 4.11-4.85%) than in the non-adherent group (3.61%; 3.16-4.06%), and the incidence of ischaemic stroke was higher in the non-adherent group (7.68%; 7.08-8.33%) than in the adherent group (5.61%; 5.17-6.07%). In terms of risk difference, adherence to OACs increased the risk of major bleeding by 0.87% and decreased the risk of ischaemic stroke by 2.08%. This finding suggests that one additional major bleeding event occurred for every 115 adherent patients, and one additional ischaemic stroke event was prevented for every 48 adherent patients. CONCLUSION The benefits of OAC adherence in NVAF patients for ischaemic stroke prevention exceeding the risk of bleeding are shown more clearly in terms of absolute risk.
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Affiliation(s)
- Won Kyung Lee
- Department of Prevention and Management, Inha University Hospital, School of Medicine, Inha University, Incheon, Republic of Korea
- Incheon Regional Cardiocerebrovascular Center, Inha University Hospital, Incheon, Republic of Korea
| | - Seong Ill Woo
- Incheon Regional Cardiocerebrovascular Center, Inha University Hospital, Incheon, Republic of Korea
- Department of Internal Medicine, Inha University Hospital, School of Medicine, Inha University, Incheon, Republic of Korea
| | - Dong Keun Hyun
- Incheon Regional Cardiocerebrovascular Center, Inha University Hospital, Incheon, Republic of Korea
- Department of Neurosurgery, Inha University Hospital, School of Medicine, Inha University, Incheon, Republic of Korea
| | - Sun-Young Jung
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
| | - Mi-Sook Kim
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joongyub Lee
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, Republic of Korea
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Patsiou V, Samaras A, Kartas A, Moysidis DV, Papazoglou AS, Bekiaridou A, Baroutidou A, Ziakas A, Tzikas A, Giannakoulas G. Prognostic implications of adherence to oral anticoagulants among patients with atrial fibrillation: Insights from MISOAC-AF trial. J Cardiol 2023; 81:390-396. [PMID: 36179772 DOI: 10.1016/j.jjcc.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
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.
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Affiliation(s)
- Vasiliki Patsiou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Samaras
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andreas S Papazoglou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Bekiaridou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Amalia Baroutidou
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Ziakas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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15
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Impacts of medication non-adherence to major modifiable stroke-related diseases on stroke prevention and mortality: a meta-analysis. J Neurol 2023; 270:2504-2516. [PMID: 36843040 PMCID: PMC9968645 DOI: 10.1007/s00415-023-11601-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Medication adherence is one of the crucial attempts in primary stroke prevention. The available evidence lacks comprehensive reviews exploring the association of medication adherence with stroke prevention. OBJECTIVES To investigate the effects of non-adherence to medications used to treat the modifiable risk of diseases on stroke-associated outcomes in primary stroke prevention. METHODS Study records were searched from PubMed, Embase, and CINAHL. Those studies reported risks relevant to stroke-associated outcomes and medication non-adherence for patients diagnosed with four modifiable stroke-related diseases (atrial fibrillation [AF], hyperlipidemia, hypertension, and type 2 diabetes mellitus) but without stroke history were included for meta-analysis and further subgroup, sensitivity, and publication bias analyses. A random effect model was performed to analyse the pooled risk estimates of relative risk (RR) and 95% confidence intervals (CIs). RESULTS Thirty-nine studies (with 2,117,789 participants in total) designed as cohort or case-control studies were included. Those patients presenting with four stroke-related diseases and categorised as medication non-adherent tended to result in stroke and/or associated death (all pooled RR ≥ 1 and 95% CI did not include 1). The findings of stratification and sensitivity analysis for each stroke-related disease showed a similar trend. Non-adherent patients with AF were prone to stroke occurrence (RR 1.852; 95% CI 1.583-2.166) but inclined to reduced bleeding (RR 0.894; 95% CI 0.803-0.996). The existence of publication bias warrants further interpretation. CONCLUSIONS Non-adherence to medications for the four stroke-related diseases contributes to the development of stroke and/or mortality in primary stroke prevention. More efforts are needed to improve patients' medication adherence.
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Ingason AB, Hreinsson JP, Lund SH, Ágústsson AS, Rumba E, Pálsson DA, Reynisson IE, Guðmundsdóttir BR, Önundarson PT, Björnsson ES. Comparison of medication adherence to different oral anticoagulants: population-based cohort study. BMJ Open 2023; 13:e065700. [PMID: 36604126 PMCID: PMC9827257 DOI: 10.1136/bmjopen-2022-065700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Previous observational studies have yielded conflicting results on whether medication adherence differs between patients receiving warfarin and direct oral anticoagulants (DOACs). Importantly, no study has adequately accounted for warfarin dosing being continuously modified based on INR values while dosing of DOACs is fixed. We aimed to compare non-adherence between new users of apixaban, dabigatran, rivaroxaban and warfarin in a population-based cohort. METHODS New users of apixaban, dabigatran, rivaroxaban and warfarin from 2014 to 2019 living in the Icelandic capital area were included. Non-adherence was defined as proportion of days covered below 80%. Inverse probability weighting was used to yield balanced study groups and non-adherence was compared using logistic regression. Factors associated with non-adherence were estimated using multivariable logistic regression. RESULTS Overall, 1266 patients received apixaban, 247 dabigatran, 1566 rivaroxaban and 768 warfarin. The proportion of patients with non-adherence ranged from 10.5% to 16.7%. Dabigatran was associated with significantly higher odds of non-adherence compared with apixaban (OR 1.57, 95% CI 1.21 to 2.04, p<0.001), rivaroxaban (OR 1.45, 95% CI 1.12 to 1.89, p=0.005) and warfarin (OR 1.63, 95% CI 1.23 to 2.15, p<0.001). The odds of non-adherence were similar for apixaban, rivaroxaban and warfarin. Apart from the type of oral anticoagulants (OACs) used, female sex, hypertension, history of cerebrovascular accident and concomitant statin use were all independently associated with lower odds of non-adherence. CONCLUSION Dabigatran was associated with higher odds of non-adherence compared with other OACs. Non-adherence was similar between apixaban, rivaroxaban and warfarin users. Female sex and higher comorbidity were associated with better medication adherence.
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Affiliation(s)
- Arnar B Ingason
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Jóhann P Hreinsson
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Goteborg, Sweden
| | | | - Arnar S Ágústsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Edward Rumba
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Daníel A Pálsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
| | | | | | - Páll T Önundarson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Laboratory Hematology, Landspitali University Hospital, Reykjavik, Iceland
| | - Einar S Björnsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
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17
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Tarn DM, Shih K, Tseng CH, Thomas A, Schwartz JB. Reasons for Nonadherence to the Direct Oral Anticoagulant Apixaban: A Cross-Sectional Survey of Atrial Fibrillation Patients. JACC. ADVANCES 2023; 2:100175. [PMID: 38939023 PMCID: PMC11198726 DOI: 10.1016/j.jacadv.2022.100175] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/22/2022] [Indexed: 06/29/2024]
Abstract
Background Nonadherence to direct oral anticoagulants to prevent stroke occurs in up to 40% of atrial fibrillation patients. Underlying reasons are poorly understood. Objectives This study quantified patient-reported reasons for nonadherence and identified strategies to improve adherence. Methods This is a cross-sectional survey of atrial fibrillation patients in 2 academic health systems who reported apixaban nonadherence. We examined patient-reported reasons for nonadherence and level of nonadherence (assessed by a validated 3-item adherence measure) using a multivariable logistic regression model. Results Of 419 study patients, 41.5% were women. The mean age was 71.1 ± 10 years and mean CHA2DS2VASc score was 3.2 ± 1.6. About two-thirds had adherence scores ≥80 (mild nonadherence) and one-third scores <80 (poor adherence). In all groups, forgetfulness contributed to nonadherence. Attitudes/beliefs associated with adherence score <80 included: not believing apixaban was needed (odds ratio [OR]: 12.24 [95% CI: 2.25-66.47]); medication cost (OR: 3.97 [95% CI: 1.67-9.42]); and fear of severe bleeding (OR: 3.28 [95% CI: 1.20-8.96]). Strategies that patients with adherence scores <80 selected as helping "a great deal/a lot" to increase adherence included bloodwork to evaluate efficacy (56%), physician counseling about adherence (55%), and having a reversal agent (39%). Almost one-half of all patients did not disclose nonadherence to their providers. Conclusions Patients may not disclose their nonadherence to prescribers, and attitudes related to apixaban nonadherence differ among patients with mild nonadherence versus poor adherence. While all patients may benefit from strategies to address forgetfulness, concerns related to the purpose of apixaban, cost, and bleeding risk may require special attention in those with poor adherence.
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Affiliation(s)
- Derjung M. Tarn
- Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, California, USA
| | - Kevin Shih
- Department of Family Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, California, USA
| | - Chi-hong Tseng
- Division of General Internal Medicine/Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, University of California-Los Angeles, Los Angeles, California, USA
| | - Alveena Thomas
- Division of Geriatrics, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Janice B. Schwartz
- Division of Geriatrics, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
- Division of Clinical Pharmacology, Departments of Medicine and Bioengineering and Therapeutic Sciences, University of California-San Francisco, San Francisco, California, USA
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18
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Bonsu KO, Young SW, Lee T, Nguyen HV, Chitsike RS. Self-reported adherence to direct oral anticoagulants versus warfarin therapy in a specialized thrombosis service-a cross-sectional study of patients in a Canadian Health Region. Eur J Clin Pharmacol 2023; 79:117-125. [PMID: 36399203 DOI: 10.1007/s00228-022-03418-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 11/05/2022] [Indexed: 11/19/2022]
Abstract
PURPOSE Direct oral anticoagulants (DOACs) have a better safety and efficacy profile than warfarin and are currently recommended for stroke prevention in non-valvular atrial fibrillation (AF) and treatment of venous thromboembolism (VTE). Given that DOACs do not require regular laboratory monitoring compared to warfarin, patients' interactions with the health care system is reduced. Adequate adherence to DOACs is important and reported adherence to anticoagulation is unclear in clinical practice. This study aims to assess self-reported adherence to oral anticoagulants in a specialized Adult Outpatient Thrombosis Service (TS). METHODS: This cross-sectional study included patients aged ≥ 18 years who were prescribed an oral anticoagulant and had attended at least one appointment with an Adult Outpatient Thrombosis Service (TS) between October 10, 2017, and May 31, 2019. Adherence to oral anticoagulant therapy was assessed using the 12-item validated Adherence to Refills and Medications Scale (ARMS) score. Logistic regression analyses were used to evaluate association between patient characteristics and medication adherence. Adherence rates in DOACs and warfarin were compared. RESULTS Three hundred and ninety-nine patients completed and returned the survey. Of the 399 who completed the survey, 74% were prescribed DOACs and 26% received warfarin. Most of the patients (89.3%) were ≥ 50 years of age and half (57.3%) were male. About two-thirds (67%) had at least post-secondary education. The duration of anticoagulation use differed between patients on DOAC and warfarin; a greater proportion of those who had used anticoagulants for less than 1 year was on DOACs compared to warfarin (20.9% vs 4.9%, p = 0.001). For patients who had been on anticoagulation for > 5 years, the proportion of warfarin patients was greater than DOAC (57.8% vs 20.5%, p = 0.001). Self-reported adherence to oral anticoagulant therapy using the 12-item ARMS scale for warfarin and DOACs were 87.3% and 90.9%, respectively. Among the warfarin users, patient satisfaction with TS was associated with medication adherence (OR = 0.22; 95% CI: 0.05-0.89). CONCLUSIONS Self-reported medication adherence was similar between warfarin and DOACs. Since suboptimal adherence is associated with poor clinical outcomes and increased costs, various stakeholders should emphasize the importance of medication adherence to oral anticoagulants at each patient encounter.
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Affiliation(s)
- Kwadwo Osei Bonsu
- School of Pharmacy, Memorial University of Newfoundland, 300 Prince Philip Drive, St John's, NL, A1B 3V6, Canada.
| | - Stephanie W Young
- School of Pharmacy, Memorial University of Newfoundland, 300 Prince Philip Drive, St John's, NL, A1B 3V6, Canada.,Pharmacy Program, Eastern Region Health Authority, 300 Prince Philip Drive, St John's, NL, A1B 3V6, Canada
| | - Tiffany Lee
- School of Pharmacy, Memorial University of Newfoundland, 300 Prince Philip Drive, St John's, NL, A1B 3V6, Canada.,Pharmacy Program, Eastern Region Health Authority, 300 Prince Philip Drive, St John's, NL, A1B 3V6, Canada
| | - Hai V Nguyen
- School of Pharmacy, Memorial University of Newfoundland, 300 Prince Philip Drive, St John's, NL, A1B 3V6, Canada
| | - Rufaro S Chitsike
- Division of Hematology, Eastern Region Health Authority, 300 Prince Philip Drive, St John's, NL, A1B 3V6, Canada.,Division of Medicine (Hematology), Memorial University of Newfoundland, 300 Prince Philip Drive, St John's, NL, A1B 3V6, Canada
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19
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Madhavan MV, Howard JP, Brener MI, Der Nigoghossian C, Chen S, Makkar R, Osmancik P, Reddy VY, Holmes DR, Stone GW, Leon MB, Ahmad Y. Long-Term Outcomes of Randomized Controlled Trials Comparing Percutaneous Left Atrial Appendage Closure to Oral Anticoagulation for Nonvalvular Atrial Fibrillation: A Meta-Analysis. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100096. [PMID: 37275318 PMCID: PMC10236864 DOI: 10.1016/j.shj.2022.100096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/28/2022] [Accepted: 08/17/2022] [Indexed: 06/07/2023]
Abstract
Background Oral anticoagulation (OAC) has been considered the standard of care for stroke prophylaxis for patients with nonvalvular atrial fibrillation; however, many individuals are unable or unwilling to take long-term OAC. The safety and efficacy of percutaneous left atrial appendage closure (LAAC) have been controversial, and new trial data have recently emerged. We therefore sought to perform an updated meta-analysis of randomized clinical trials (RCTs) comparing OAC to percutaneous LAAC, focusing on individual clinical endpoints. Methods We performed a systematic search of the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from January 2000 through December 2021 for all RCTs comparing percutaneous LAAC to OAC in patients with nonvalvular atrial fibrillation. Fixed and random effects meta-analyses of hazard ratios (HRs) were performed using the longest follow-up duration available by intention-to-treat. The prespecified primary endpoint was all-cause mortality. Results Three RCTs enrolling 1516 patients were identified. The weighted mean follow-up was 54.7 months. LAAC was associated with a reduced risk of all-cause mortality (HR 0.76; 95% confidence interval [CI], 0.59-0.96; p = 0.023), hemorrhagic stroke (HR 0.24; 95% CI, 0.09-0.61; p = 0.003), and major nonprocedural bleeding (HR 0.52; 95% CI, 0.37-0.74; p < 0.001). There was no significant difference between LAAC and OAC for any other endpoints. Conclusions The available evidence from RCTs suggests LAAC therapy is associated with reduced long-term risk of death compared with OAC. This may be driven by reductions in hemorrhagic stroke and major nonprocedural bleeding. There were no significant differences in the risk of all stroke. Further large-scale clinical trials are needed to validate these findings.
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Affiliation(s)
- Mahesh V. Madhavan
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - James P. Howard
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael I. Brener
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
| | - Caroline Der Nigoghossian
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
| | - Shmuel Chen
- Cardiovascular Research Foundation, New York, New York, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Pavel Osmancik
- Cardiocenter, Third Faculty of Medicine, Charles University Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Vivek Y. Reddy
- The Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David R. Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Martin B. Leon
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
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20
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Sporn ZA, Berman AN, Daly D, Wasfy JH. Improving guideline-based anticoagulation in atrial fibrillation: A systematic literature review of prospective trials. Heart Rhythm 2023; 20:69-75. [PMID: 36122695 DOI: 10.1016/j.hrthm.2022.09.011] [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: 08/13/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Guidelines for anticoagulation in patients with atrial fibrillation (AF) aim to decrease the risk of ischemic stroke. However, there is a gap in actual practice between patients who have an indication for anticoagulation and those who are actually prescribed anticoagulation. OBJECTIVE We sought to evaluate the efficacy of prior population-based interventions aimed at decreasing this AF anticoagulation gap. METHODS This study was prospectively registered in the International Prospective Register of Systematic Reviews database (CRD42021287875). A systematic literature review was conducted to obtain all prospective individually randomized and cluster randomized trials by searching 4 electronic databases: PubMed, Google Scholar, Web of Science, and Medline. RESULTS After a review of 1474 studies, 20 trials were included in this systematic literature review. Forty-five percent were effective in decreasing the AF anticoagulation gap. Trial interventions that improved anticoagulation prescribing included 6 trials of electronic risk assessment or decision support, 1 trial of provider education, 2 trials of new protocol or pathway, and 2 trials of patient education. Six of 15 ambulatory trials, 2 of 4 inpatient trials, and 1 trial that spanned inpatient and outpatient settings improved anticoagulation prescribing rates. Interventions focused on patient education, provider education, and electronic risk assessment or decision support increased absolute appropriate anticoagulation prescribing by 8.3%, 4.9%, and 2.0%, respectively. CONCLUSION Interventions aimed at improving anticoagulation prescribing patterns in AF can be effective, although there is heterogeneity in outcomes across intervention type. The most effective interventions appeared to target patient education, provider education, and electronic risk assessment or decision support.
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Affiliation(s)
- Zachary A Sporn
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
| | - Adam N Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Danielle Daly
- Population Health Management, Performance Analysis and Improvement, Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts
| | - Jason H Wasfy
- Population Health Management, Performance Analysis and Improvement, Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts; Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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21
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Omran H, Büllesfeld L, Heinrich J. Der interventionelle Vorhofohrverschluss: eine Alternative zur oralen Antikoagulation. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1953-0255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ZusammenfassungDie orale Antikoagulation ist der Standard zur Prävention von Embolien bei Patienten mit Vorhofflimmern. Der interventionelle Vorhofohrverschluss ist eine Alternative zur oralen
Antikoagulation bei Patienten mit Vorhofflimmern und Kontraindikationen oder Unverträglichkeiten einer oralen Antikoagulation, insbesondere bei klinisch relevanten Blutungen. Die Sicherheit
des Verfahrens hat in den letzten Jahren erheblich zugenommen. Mehrere große randomisierte Studien vergleichen aktuell die Effektivität und Sicherheit der oralen Antikoagulation und des
interventionellen Vorhofohrverschlusses.
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Affiliation(s)
- Heyder Omran
- Innere Medizin/Kardiologie, GFO Kliniken Bonn Betriebsstätte St. Marien, Bonn, Deutschland
| | - Lutz Büllesfeld
- Innere Medizin/Kardiologie, GFO Kliniken Bonn Betriebsstätte St. Marien, Bonn, Deutschland
| | - Jaroslaw Heinrich
- Innere Medizin/Kardiologie, GFO Kliniken Bonn Betriebsstätte St. Marien, Bonn, Deutschland
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22
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Troshina DV, Andreev DA, Fomicheva AV, Volovchenko AN, Volel BA. Social and psychological risk factors for decreased adherence among patients with atrial fibrillation. TERAPEVT ARKH 2022; 94:1197-1203. [DOI: 10.26442/00403660.2022.10.201905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Indexed: 11/23/2022]
Abstract
Adherence has a direct impact on reducing the effectiveness of atrial fibrillation therapy and increasing the risk of thromboembolic events. Among the factors involved in the decrease of adherence, the social and psychological characteristics of patients remain insufficiently studied. At the same time, the available publications allow us to conclude that there are markers of the risk of reduced adherence in patients with atrial fibrillation, which include age, cognitive impairment, psychoemotional disorders (including depression and anxiety) and specific behavioral patterns.
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23
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Delavar A, Baxter SL. Cilioretinal artery occlusion in antiphospholipid syndrome and the decision to anticoagulate. BMJ Case Rep 2022; 15:e249509. [PMID: 36384882 PMCID: PMC9670929 DOI: 10.1136/bcr-2022-249509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A patient in her late 50s with antiphospholipid syndrome presented to general ophthalmology clinic for annual hydroxychloroquine retinopathy screening. She had taken 400 mg hydroxychloroquine daily for over a decade. She denied any visual changes and visual acuity was 20/20. Her examination and fundus photos were normal, but macular optical coherence tomography of the right eye demonstrated inner retinal atrophy and visual field tests revealed a corresponding paracentral scotoma, consistent with a prior cilioretinal artery occlusion. Prior testing from visits with other ophthalmologists revealed that this occlusion had occurred previously, but she had only been informed of not having hydroxychloroquine retinopathy. The possibility of vision loss prompted her to reconsider her prior decision to discontinue anticoagulation. This case demonstrates how anchoring bias may lead clinicians astray, and how the risk of blindness is a strong motivator for patients regarding anticoagulation.
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Affiliation(s)
- Arash Delavar
- Department of Ophthalmology, University of California, La Jolla, California, USA
- Department of Medicine, Division of Biomedical Informatics, University of California, La Jolla, California, USA
| | - Sally L Baxter
- Department of Ophthalmology, University of California, La Jolla, California, USA
- Department of Medicine, Division of Biomedical Informatics, University of California, La Jolla, California, USA
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24
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Oral anticoagulants: a systematic overview of reviews on efficacy and safety, genotyping, self-monitoring, and stakeholder experiences. Syst Rev 2022; 11:232. [PMID: 36303235 PMCID: PMC9615370 DOI: 10.1186/s13643-022-02098-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 10/08/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND This systematic overview was commissioned by England's Department of Health and Social Care (DHSC) to assess the evidence on direct (previously 'novel') oral anticoagulants (OACs), compared with usual care, in adults, to prevent stroke related to atrial fibrillation (AF), and to prevent and treat venous thromboembolism (VTE). Specifically, to assess efficacy and safety, genotyping, self-monitoring, and patient and clinician experiences of OACs. METHODS We searched MEDLINE, Embase, ASSIA, and CINAHL, in October, 2017, updated in November 2021. We included systematic reviews, published from 2014, in English, assessing OACs, in adults. We rated review quality using AMSTAR2 or the JBI checklist. Two reviewers extracted and synthesised the main findings from the included reviews. RESULTS We included 49 systematic reviews; one evaluated efficacy, safety, and cost-effectiveness, 17 assessed genotyping, 23 self-monitoring or adherence, and 15 experiences (seven assessed two topics). Generally, the direct OACs, particularly apixaban (5 mg twice daily), were more effective and safer than warfarin in preventing AF-related stroke. For VTE, there was little evidence of differences in efficacy between direct OACs and low-molecular-weight heparin (prevention), warfarin (treatment), and warfarin or aspirin (secondary prevention). The evidence suggested that some direct OACs may reduce the risk of bleeding, compared with warfarin. One review of genotype-guided warfarin dosing assessed AF patients; no significant differences in stroke prevention were reported. Education about OACs, in patients with AF, could improve adherence. Pharmacist management of coagulation may be better than primary care management. Patients were more adherent to direct OACs than warfarin. Drug efficacy was highly valued by patients and most clinicians, followed by safety. No other factors consistently affected patients' choice of anticoagulant and adherence to treatment. Patients were more satisfied with direct OACs than warfarin. CONCLUSIONS For stroke prevention in AF, direct OACs seem to be more effective and safer than usual care, and apixaban (5 mg twice daily) had the best profile. For VTE, there was no strong evidence that direct OACs were better than usual care. Education and pharmacist management could improve coagulation control. Both clinicians and patients rated efficacy and safety as the most important factors in managing AF and VTE. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017084263-one deviation; efficacy and safety were from one review.
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25
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Huijboom M, Maarse M, Aarnink E, van Dijk V, Swaans M, van der Heijden J, IJsselmuiden S, Folkeringa R, Blaauw Y, Elvan A, Stevenhagen J, Vlachojannis G, van der Voort P, Westra S, Chaldoupi M, Khan M, de Groot J, van der Kley F, van Mieghem N, van Dijk E, Dijkgraaf M, Tijssen J, Boersma L. COMPARE LAAO: Rationale and design of the randomized controlled trial "COMPARing Effectiveness and safety of Left Atrial Appendage Occlusion to standard of care for atrial fibrillation patients at high stroke risk and ineligible to use oral anticoagulation therapy". Am Heart J 2022; 250:45-56. [PMID: 35537503 DOI: 10.1016/j.ahj.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) provides an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). In patients with a long-term or permanent contraindication for OAC randomized controlled trial (RCT) data is lacking. STUDY OBJECTIVES To assess the efficacy and safety of LAAO in AF patients who are ineligible to use OAC. The co-primary efficacy endpoint is (1) time to first occurrence of stroke (ischemic, hemorrhagic, or undetermined) and (2) time to first occurrence of the composite of stroke, transient ischemic attack (TIA), and systemic embolism (SE). The primary safety endpoint is the 30-day rate of peri-procedural complications. STUDY DESIGN This is a multicenter, investigator-initiated, open-label, blinded endpoint (PROBE), superiority-driven RCT. Patients with AF, a CHA₂DS₂-VASc score ≥2 for men and ≥3 for women and a long-term or permanent contraindication for OAC will be randomized in a 2:1 fashion to the device- or control arm. Patients in the device arm will undergo percutaneous LAAO and will receive post-procedural dual antiplatelet therapy (DAPT) per protocol, while those in the control arm will continue their current treatment consisting of no antithrombotic therapy or (D)APT as deemed appropriate by the primary responsible physician. In this endpoint-driven trial design, assuming a 50% lower stroke risk of LAAO compared to conservative treatment, 609 patients will be followed for a minimum of 1 and a maximum of 5 years. Cost-effectiveness and budget impact analyses will be performed to allow decision-making on reimbursement of LAAO for the target population in the Netherlands. SUMMARY The COMPARE LAAO trial will investigate the clinical superiority in preventing thromboembolic events and cost-effectiveness of LAAO in AF patients with a high thromboembolic risk and a contraindication for OAC use. NCT TRIAL NUMBER NCT04676880.
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Affiliation(s)
- Marina Huijboom
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands; Amsterdam University Medical Center, location AMC, Cardiology Department, Amsterdam, The Netherlands.
| | - Moniek Maarse
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands; Amsterdam University Medical Center, location AMC, Cardiology Department, Amsterdam, The Netherlands
| | - Errol Aarnink
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands; Amsterdam University Medical Center, location AMC, Cardiology Department, Amsterdam, The Netherlands
| | - Vincent van Dijk
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Martin Swaans
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | - Richard Folkeringa
- Medical Center Leeuwarden, Cardiology Department, Leeuwarden, The Netherlands
| | - Yuri Blaauw
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Arif Elvan
- Cardiology Department, Isala Hospital, Zwolle, The Netherlands
| | - Jeroen Stevenhagen
- Medical Spectrum Twente, Department of Cardiology, Enschede, The Netherlands
| | - George Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Sjoerd Westra
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marisevi Chaldoupi
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Muchtiar Khan
- Cardiology Department, OLVG, Amsterdam, The Netherlands
| | - Joris de Groot
- Amsterdam University Medical Center, location AMC, Cardiology Department, Amsterdam, The Netherlands
| | - Frank van der Kley
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nicolas van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ewoud van Dijk
- Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel Dijkgraaf
- Location AMC, Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jan Tijssen
- Clinical Epidemiology & Biostatistics, Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lucas Boersma
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands; Amsterdam University Medical Center, location AMC, Cardiology Department, Amsterdam, The Netherlands
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Huijboom MF, Boersma LV. Left atrial appendage occlusion is underutilized. Heart Rhythm O2 2022; 3:444-447. [PMID: 36097456 PMCID: PMC9463706 DOI: 10.1016/j.hroo.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Wilkinson C, Wu J, Clegg A, Nadarajah R, Rockwood K, Todd O, Gale CP. Impact of oral anticoagulation on the association between frailty and clinical outcomes in people with atrial fibrillation: nationwide primary care records on treatment analysis. Europace 2022; 24:1065-1075. [PMID: 35244709 PMCID: PMC9326851 DOI: 10.1093/europace/euac022] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/04/2022] [Indexed: 12/04/2022] Open
Abstract
AIMS People with atrial fibrillation (AF) frequently live with frailty, which increases the risk of mortality and stroke. This study reports the association between oral anticoagulation (OAC) and outcomes for people with frailty, and whether there is overall net benefit from treatment in people with AF. METHODS AND RESULTS Retrospective open cohort electronic records study. Frailty was identified using the electronic frailty index. Primary care electronic health records of 89 996 adults with AF and CHA2DS2-Vasc score of ≥2 were linked with secondary care and mortality data in the Clinical Practice Research Database (CPRD) from 1 January 1998 to 30 November 2018. The primary outcome was a composite of death, stroke, systemic embolism, or major bleeding. Secondary outcomes were stroke, major bleeding, all-cause mortality, transient ischaemic attack, and falls. Of 89 996 participants, 71 256 (79.2%) were living with frailty. The prescription of OAC increased with degree of frailty. For patients not prescribed OAC, rates of the primary outcome increased alongside frailty category. Prescription of OAC was associated with a reduction in the primary outcome for each frailty category [adjusted hazard ratio, 95% confidence interval, no OAC as reference; fit: vitamin K antagonist (VKA) 0.69, 0.64-0.75, direct oral anticoagulant (DOAC) 0.42, 0.33-0.53; mild frailty: VKA 0.52, 0.50-0.54, DOAC 0.57, 0.52-0.63; moderate: VKA 0.54, 0.52-0.56, DOAC 0.57, 0.52-0.63; severe: VKA 0.48, 0.45-0.51, DOAC 0.58, 0.52-0.65], with cumulative incidence function effects greater for DOAC than VKA. CONCLUSION Frailty among people with AF is common. The OAC was associated with a reduction in the primary endpoint across all degrees of frailty.
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Affiliation(s)
- Chris Wilkinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Jianhua Wu
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Leeds Institute for Data Analytics, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
| | - Andrew Clegg
- Academic Unit for Ageing and Stroke Research, Leeds Institute of Health Sciences, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ramesh Nadarajah
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Leeds Institute for Data Analytics, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
| | - Kenneth Rockwood
- Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Oliver Todd
- Academic Unit for Ageing and Stroke Research, Leeds Institute of Health Sciences, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Leeds Institute for Data Analytics, University of Leeds, 6.090a Worsley Building, Leeds LS2 9JT, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Alkhameys S, Barrett R. Impact of the COVID-19 pandemic on England's national prescriptions of oral vitamin K antagonist (VKA) and direct-acting oral anticoagulants (DOACs): an interrupted time series analysis (January 2019-February 2021). Curr Med Res Opin 2022; 38:1081-1092. [PMID: 35582854 DOI: 10.1080/03007995.2022.2078100] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Direct-acting oral anticoagulants (DOACs) were developed as an alternative to warfarin to treat and prevent thromboembolism, including stroke prevention in non-valvular atrial fibrillation patients. The COVID-19 pandemic could increase the risk of stroke and/or the risk of bleeding in patients due to nonadherence or sub/supra-optimal dosing. OBJECTIVE To investigate DOAC prescription trends in England's community settings during the complete first wave of COVID-19 pandemic. METHODS Descriptive and interrupted time series (ITS) analyses were conducted to examine the prescription patterns of DOACs (dabigatran, rivaroxaban, apixaban and edoxaban) and warfarin for primary care patients in the English Prescribing Dataset from January 2019 to February 2021, with March 2020 as the cut-off point. RESULTS A 19% increase in mean DOAC's accompanied with 20% warfarin prescriptions decline was observed. ITS modelling showed an increase in DOAC prescription volume in March 2020 (+7 million items, p = 0.008). The pre-existing upward trend in DOAC prescriptions slowed during the period (-427,000 items, p = 0.007). Apixaban was the most frequently used DOAC and had the largest step-change in March 2020 (+5 million items, p = 0.010). The mean monthly combined cost of DOACs and warfarin was higher during the period. DOAC prescription trends were consistent across England's regions. Conclusion: The overall oral anticoagulants use in this period was lower than expected, indicating a medical needs gap, possibly due to adherence issues. The potential clinical and logistical consequences warrant further study to identify contributing factors and mitigate avoidable risks.
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Affiliation(s)
| | - Ravina Barrett
- Senior Lecturer in Pharmacy Practice, School of Applied Sciences, Cockcroft Building, University of Brighton, Brighton, UK
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Masiliūnas R, Dapkutė A, Grigaitė J, Lapė J, Valančius D, Bacevičius J, Katkus R, Vilionskis A, Klimašauskienė A, Ekkert A, Jatužis D. High Prevalence of Atrial Fibrillation in a Lithuanian Stroke Patient Cohort. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060800. [PMID: 35744063 PMCID: PMC9230037 DOI: 10.3390/medicina58060800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with a five-fold increased risk for acute ischemic stroke (AIS). We aimed to estimate the prevalence of AF in a Lithuanian cohort of stroke patients, and its impact on patients regarding case fatality, functional outcome, and health-related quality of life (HRQoL) at 90 days. Materials and Methods: A single-center prospective study was carried out for four non-consecutive months between December 2018 and July 2019 in one of the two comprehensive stroke centers in Eastern Lithuania. A telephone-based follow-up was conveyed at 90 days using the modified Rankin Scale (mRS) and EuroQoL five-dimensional three-level descriptive system (EQ-5D-3L) with a self-rated visual analog scale (EQ-VAS). One-year case fatality was investigated. Results: We included 238 AIS patients with a mean age of 71.4 ± 11.9 years of whom 45.0% were female. A striking 97 (40.8%) AIS patients had a concomitant AF, in 68 (70.1%) of whom the AF was pre-existing. The AIS patients with AF were at a significantly higher risk for a large vessel occlusion (LVO; odds ratio 2.72 [95% CI 1.38−5.49], p = 0.004), and had a more severe neurological impairment at presentation (median NIHSS score (interquartile range): 9 (6−16) vs. 6 (3−9), p < 0.001). The LVO status was only detected in those who had received computed tomography angiography. Fifty-five (80.9%) patients with pre-existing AF received insufficient anticoagulation at stroke onset. All patients received a 12-lead ECG, however, in-hospital 24-h Holter monitoring was only performed in 3.4% of AIS patients without pre-existing AF. Although multivariate analyses found no statistically significant difference in one-year stroke patient survival and favorable functional status (mRS 0−2) at 90 days, when adjusted for age, gender, reperfusion treatment, baseline functional status, and baseline NIHSS, stroke patients with AF had a significantly poorer self-perceived HRQoL, indicated by a lower EQ-VAS score (regression coefficient ± standard error: β = −11.776 ± 4.850, p = 0.017). Conclusions: In our single-center prospective observational study in Lithuania, we found that 40.8% of AIS patients had a concomitant AF, were at a higher risk for an LVO, and had a significantly poorer self-perceived HRQoL at 90 days. Despite the high AF prevalence, diagnostic tools for subclinical AF were greatly underutilized.
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Affiliation(s)
- Rytis Masiliūnas
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
- Correspondence: ; Tel.: +370-688-62356
| | - Austėja Dapkutė
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Julija Grigaitė
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Jokūbas Lapė
- Faculty of Medicine, Vilnius University, 03101 Vilnius, Lithuania;
| | - Domantas Valančius
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Justinas Bacevičius
- Center of Cardiology and Angiology, Vilnius University, 08661 Vilnius, Lithuania; (J.B.); (R.K.)
| | - Rimgaudas Katkus
- Center of Cardiology and Angiology, Vilnius University, 08661 Vilnius, Lithuania; (J.B.); (R.K.)
| | | | - Aušra Klimašauskienė
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Aleksandra Ekkert
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
| | - Dalius Jatužis
- Center of Neurology, Vilnius University, 08661 Vilnius, Lithuania; (A.D.); (J.G.); (D.V.); (A.K.); (A.E.); (D.J.)
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Salmasi S, Safari A, Kapanen A, Adelakun A, Kwan L, MacGillivray J, Andrade JG, Deyell MW, Loewen P. Oral anticoagulant adherence and switching in patients with atrial fibrillation: A prospective observational study. Res Social Adm Pharm 2022; 18:3920-3928. [PMID: 35753963 DOI: 10.1016/j.sapharm.2022.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Adherence to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) is important in preventing stroke. The dominance of retrospective studies using administrative data has led to a lack of data on psychosocial determinants of adherence and prevented comparison of adherence between OAC drug classes. OAC switching is another aspect of adherence that is unexplored. METHODS A prospective design was utilized to measure AF patients' self-reported adherence and OAC switching, and to identify their clinical, demographic, and psychosocial determinants. Participants were recruited from specialized AF clinics in Canada and followed for up to 2 years. Data were collected via telephone every 3-4 months using a structured survey. Adherence was measured using the Morisky Medication Adherence scale (©MMAS-8). RESULTS The included participants (N = 306) were followed for a median follow up time of 14.1 months and had an average of 3.2(SD 1.4) study visits. The mean self-reported adherence on the ©MMAS-8 was 7.28(SD 0.71) for patients receiving care at specialized AF clinics. Older age, experiencing a bleed, and higher satisfaction with the burden of medications were significantly associated with higher adherence. Drug class did not have any significant impact on adherence. 7.8% of the cohort experienced a switch with most of them being from warfarin to DOAC. Taking warfarin as the index medication, experiencing a bleed and older age were significantly associated with higher odds of switching. CONCLUSION Patients with AF reported high adherence to their OAC therapy however being on DOAC may not translate to better adherence compared to VKA. Improving satisfaction with the burden of therapy is important in improving adherence.
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Affiliation(s)
- Shahrzad Salmasi
- Collaboration for Outcomes Research & Evaluation (CORE), University of British Columbia, Vancouver, BC, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Canada
| | - Abdollah Safari
- Faculty of Pharmaceutical Sciences, University of British Columbia, Canada; Data Analytics, Statistics and Informatics, Faculty of Pharmaceutical Sciences, University of British Columbia, Canada
| | - Anita Kapanen
- Collaboration for Outcomes Research & Evaluation (CORE), University of British Columbia, Vancouver, BC, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Canada
| | - Adenike Adelakun
- Collaboration for Outcomes Research & Evaluation (CORE), University of British Columbia, Vancouver, BC, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Canada
| | - Leanne Kwan
- Atrial Fibrillation Clinic, Royal Columbian Hospital, New Westminster, Canada
| | - Jenny MacGillivray
- Atrial Fibrillation Clinic, Vancouver General Hospital, Vancouver, Canada
| | - Jason G Andrade
- Atrial Fibrillation Clinic, Vancouver General Hospital, Vancouver, Canada; Division of Cardiology, Faculty of Medicine, The University of British Columbia, Canada; UBC Centre for Cardiovascular Innovation, Vancouver, Canada
| | - Marc W Deyell
- Division of Cardiology, Faculty of Medicine, The University of British Columbia, Canada; UBC Centre for Cardiovascular Innovation, Vancouver, Canada; Atrial Fibrillation Clinic, St. Paul's Hospital, Vancouver, Canada
| | - Peter Loewen
- Collaboration for Outcomes Research & Evaluation (CORE), University of British Columbia, Vancouver, BC, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Canada; UBC Centre for Cardiovascular Innovation, Vancouver, Canada.
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Toma MM, Bungau SG, Tit DM, Moisi MI, Bustea C, Vesa CM, Behl T, Stoicescu M, Brisc CM, Purza LA, Gitea D, Diaconu CC. Use of anticoagulant drugs in patients with atrial fibrillation. Does adherence to therapy have a prognostic impact? Biomed Pharmacother 2022; 150:113002. [PMID: 35462339 DOI: 10.1016/j.biopha.2022.113002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/10/2022] [Accepted: 04/17/2022] [Indexed: 11/30/2022] Open
Abstract
Anticoagulant therapy represents a pivotal element that strongly influences the thromboembolic risk of non-valvular atrial fibrillation (NVAF) subjects. The main purpose of this review was to identify issues and suggest strategies to improve the oral anticoagulants (OACs) treatment adherence, which is the most important predictor of NVAF outcome. Advantages, efficacy, and impact of these drugs on patients' prognosis were revealed in important clinical trials on large cohorts of patients and are often prescribed nowadays. A real-life data registry, the Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD-AF) analyzed the profile and outcome of patients diagnosed with NVAF receiving oral antithrombotic treatment. The observations gathered in the registry were crucial for identifying relevant elements that clinicians must improve, such as adherence strategies and predisposing factors that correlated with stroke. Adherence to OACs in AF patients is essential from the viewpoint of clinical efficacy and safety. Major adverse events and negative outcome are correlated with a weak anticoagulation control caused by an ineffective treatment adherence strategy. Solving the issue of oral anticoagulation adherence is possible using new technologies, but future directions should be explored. Mobile phone applications centered on patients' needs, telemedicine programs that evaluate patients' evolution and detect adverse reactions or events, encouraging an adequate management of the event without interruption of OACs, represent perspectives with a major impact on treatment adherence.
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Affiliation(s)
- Mirela Marioara Toma
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania.
| | - Simona Gabriela Bungau
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania; Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Delia Mirela Tit
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea 410087, Romania; Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Madalina Ioana Moisi
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy of Oradea, University of Oradea, 410073 Oradea, Romania.
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, 140401 Punjab, India.
| | - Manuela Stoicescu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania.
| | - Cristina Mihaela Brisc
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania.
| | - Lavinia Anamaria Purza
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Daniela Gitea
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410028, Romania.
| | - Camelia Cristina Diaconu
- Department 5, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania; Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania.
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Salmasi S, Högg T, Safari A, De Vera MA, Lynd LD, Koehoorn M, Barry AR, Andrade JG, Loewen P. The Random Effects Warfarin Days' Supply (REWarDS) Model: Development and Validation of a Novel Method for Estimating Exposure to Warfarin Using Administrative Data. Am J Epidemiol 2022; 191:1116-1124. [PMID: 35015808 DOI: 10.1093/aje/kwab295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/26/2021] [Accepted: 12/23/2021] [Indexed: 11/15/2022] Open
Abstract
Warfarin's complex dosing is a significant barrier to measurement of its exposure in observational studies using population databases. Using population-based administrative data (1996-2019) from British Columbia, Canada, we developed a method based on statistical modeling (Random Effects Warfarin Days' Supply (REWarDS)) that involves fitting a random-effects linear regression model to patients' cumulative dosage over time for estimation of warfarin exposure. Model parameters included a minimal universally available set of variables from prescription records for estimation of patients' individualized average daily doses of warfarin. REWarDS estimates were validated against a reference standard (manual calculation of the daily dose using the free-text administration instructions entered by the dispensing pharmacist) and compared with alternative methods (fixed window, fixed tablet, defined daily dose, and reverse wait time distribution) using Pearson's correlation coefficient (r), the intraclass correlation coefficient, and the root mean squared error. REWarDS-estimated days' supply showed strong correlation and agreement with the reference standard (r = 0.90 (95% confidence interval (CI): 0.90, 0.90); intraclass correlation coefficient = 0.95 (95% CI: 0.94, 0.95); root mean squared error = 8.24 days) and performed better than all of the alternative methods. REWarDS-estimated days' supply was valid and more accurate than estimates from all other available methods. REWarDS is expected to confer optimal precision in studies measuring warfarin exposure using administrative data.
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Lee MY, Han S, Bang OY, On YK, Jang SW, Han S, Ryu J, Park YJ, Kang S, Suh HS, Kim YH. Drug Utilization Pattern of Oral Anticoagulants in Patients with Atrial Fibrillation: A Nationwide Population-Based Study in Korea. Adv Ther 2022; 39:3112-3130. [PMID: 35524839 DOI: 10.1007/s12325-022-02151-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 03/28/2022] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Treatment persistence for anticoagulant therapy is important in preventing thromboembolism in nonvalvular atrial fibrillation (NVAF) patients. Understanding drug utilization pattern and treatment changes in oral anticoagulant (OAC) users may facilite better NVAF management. Thus, our study aimed to examine OAC treatment patterns preceding events leading to switch or discontinuation and medication adherence in Korean NVAF patients. METHODS We conducted a drug utilization study on all Korean patients with atrial fibrillation (AF) newly prescribed OACs between July 2015 and November 2016 using the national claims data. We assessed treatment changes such as switching and discontinuation from index OAC and relevant events preceding the change and examined patient characteristics as predictors of changes that occurred among OAC users. Medication adherence was compared among OAC users by calculating the medication possession ratio (MPR). RESULTS A total of 48,389 NVAF patients were identified who initiated OACs within the study period. Most initiated nonvitamin K antagonist oral anticoagulants (NOACs) (22% apixaban, 24% dabigatran, 37% rivaroxaban), and 18% initiated warfarin. The frequency of switch to another OAC was 8.8% for apixaban, 16.1% for dabigatran, 6.6% for rivaroxaban, and 19.1% for warfarin. The frequency of discontinuation was lower for apixaban (22.9%), dabigatran (26.3%), and rivaroxaban (25.7%) than warfarin (31.6%). Compared to warfarin, NOAC users were less likely to switch treatment. Thromboembolic event was the most common clinical event preceding switch from warfarin to NOAC and from NOAC to warfarin. Discontinuation of OAC was often preceded by a bleeding event. Patients who initiated apixaban showed significantly higher mean MPR compared to those on dabigatran and warfarin. CONCLUSION In real-world practice in Korea, we have observed treatment change to be common in OAC users. Our results indicate better medication adherence with NOACs than with warfarin. (ClinicalTrials.gov registration number NCT03572972).
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Di Pietro S, Ferrari I, Re B, Perlini S. Patient adherence and comprehension of take-home anticoagulant regimens prescribed at the emergency department: preliminary findings from a randomized controlled trial and implications for patient safety. Intern Emerg Med 2022; 17:921-924. [PMID: 34727287 DOI: 10.1007/s11739-021-02872-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/13/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Santi Di Pietro
- Emergency Medicine Unit and Emergency Medicine Postgraduate Training Program, IRCCS Policlinico San Matteo Foundation, Department of Internal Medicine, University of Pavia, Pavia, Italy.
| | - Ilaria Ferrari
- Emergency Medicine Unit and Emergency Medicine Postgraduate Training Program, IRCCS Policlinico San Matteo Foundation, Department of Internal Medicine, University of Pavia, Pavia, Italy
| | - Beatrice Re
- Medical Graduate, University of Pavia, Pavia, Italy
| | - Stefano Perlini
- Emergency Medicine Unit and Emergency Medicine Postgraduate Training Program, IRCCS Policlinico San Matteo Foundation, Department of Internal Medicine, University of Pavia, Pavia, Italy
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Camm AJ, Blomström-Lundqvist C, Boriani G, Goette A, Kowey PR, Merino JL, Piccini JP, Saksena S, Reiffel JA. AIM-AF: A Physician Survey in the United States and Europe. J Am Heart Assoc 2022; 11:e023838. [PMID: 35243874 PMCID: PMC9075271 DOI: 10.1161/jaha.121.023838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Guideline recommendations are the accepted reference for selection of therapies for rhythm control of atrial fibrillation (AF). This study was designed to understand physicians’ treatment practices and adherence to guidelines. Methods and Results The AIM‐AF (Antiarrhythmic Medication for Atrial Fibrillation) study was an online survey of clinical cardiologists and electrophysiologists that was conducted in the United States and Europe (N=629). Respondents actively treated ≥30 patients with AF who received drug therapy, and had received or were referred for ablation every 3 months. The survey comprised 96 questions on physician demographics, AF types, and treatment practices. Overall, 54% of respondents considered guidelines to be the most important nonpatient factor influencing treatment choice. Across most queried comorbidities, amiodarone was selected by 60% to 80% of respondents. Other nonadherent usage included sotalol by 21% in patients with renal impairment; dofetilide initiation (16%, United States only) outside of hospital; class Ic agents by 6% in coronary artery disease; and dronedarone by 8% in patients with heart failure with reduced ejection fraction. Additionally, rhythm control strategies were frequently chosen in asymptomatic AF (antiarrhythmic drugs [AADs], 35%; ablation, 8%) and subclinical AF (AADs, 38%; ablation, 13%). Despite guideline algorithms emphasizing safety first, efficacy (48%) was selected as the most important consideration for AAD choice, followed by safety (34%). Conclusions Despite surveyed clinicians recognizing the importance of guidelines, nonadherence was frequently observed. While deviation may be reasonable in selected patients, in general, nonadherence has the potential to compromise patient safety. These findings highlight an underappreciation of the safe use of AADs, emphasizing the need for interventions to support optimal AAD selection.
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Affiliation(s)
| | | | | | - Andreas Goette
- Department of Cardiology and Intensive Care Medicine St Vincenz Hospital Paderborn Paderborn Germany
| | - Peter R Kowey
- Sidney Kimmel Medical College at Thomas Jefferson University Philadelphia PA.,Lankenau Heart Institute Philadelphia PA
| | - Jose L Merino
- La Paz University Hospital, Idipaz, Autonoma University Madrid Spain
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Hijazi Y, Karkabi B, Feldman M, Malca B, Lavi I, Jaffe R, Schliamser JE, Shiran A, Flugelman MY. Bridging Care Transition After Hospitalization for Atrial Fibrillation and Coronary Interventions. J Cardiovasc Pharmacol 2022; 79:304-310. [PMID: 34803152 DOI: 10.1097/fjc.0000000000001180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/23/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Treatment fragmentation between hospitals and the community can result in catastrophic outcomes; uninterrupted treatment with anticoagulant and platelet aggregation inhibitors is particularly important. We assessed the proportion and characteristics of patients who did not visit their primary community-based physician within 1 week of discharge from our department of cardiovascular medicine and the proportion that failed to procure essential drugs at the community pharmacy. We prospectively studied 423 patients who were discharged from our department. They were provided detailed explanations, tablets for 7 days, prescriptions, and a printed drug plan. We traced the time from discharge until a visit with a primary community-based physician, and the time until the procurement of medications, using our computerized community-hospital-integrated system. Complete data were available for 313 patients, of whom 220 were treated with anticoagulants or platelet aggregation inhibitors. For 175 patients, these drugs were initiated during index hospitalizations. Only 1 patient did not receive platelet aggregation inhibitors despite recommendations. Seventy-nine patients (25%) first visited their primary care physicians more than 1 week after discharge. Predictors for delayed visits were living alone (hazard ratio 1.91) and having an in-house caregiver (hazard ratio 2.01). In conclusion, all but 1 patient continued drug therapy after discharge from the hospital. The simple predischarge steps included patient education and provision of a 1-week supply of tablets and prescriptions. Treatment continuation was independent of visits to the community-based primary physician. Patients living alone or with an in-house caregiver more often delayed visits to primary physicians yet continued relevant drug therapy.
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Affiliation(s)
- Yosef Hijazi
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, and the Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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Kamil AA, Lim KK, Koleva-Kolarova R, Chowienczyk P, Wolfe CDA, Fox-Rushby J. Genetic-Guided Pharmacotherapy for Atrial Fibrillation: A Systematic and Critical Review of Economic Evaluations. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:461-472. [PMID: 35227459 DOI: 10.1016/j.jval.2021.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/06/2021] [Accepted: 09/29/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study aimed to examine the extent and quality of evidence from economic evaluations (EEs) of genetic-guided pharmacotherapy (PGx) for atrial fibrillation (AF) and to identify variables influential in changing base-case conclusions. METHODS From systematic searches, we included EEs of existing PGx testing to guide pharmacotherapy for AF, without restrictions on population characteristics or language. Articles excluded were genetic tests used to guide device-based therapy or focused on animals. RESULTS We found 18 EEs (46 comparisons), all model-based cost-utility analysis with or without cost-effectiveness analysis mostly from health system's perspectives, of PGx testing to determine coumadin/direct-acting anticoagulant (DOAC) dosing (14 of 18), to stratify patients into coumadin/DOACs (3 of 18), or to increase patients' adherence to coumadin (1 of 18) versus non-PGx. Most PGx to determine coumadin dosing found PGx more costly and more effective than standard or clinical coumadin dosing (19 of 24 comparisons) but less costly and less effective than standard DOAC dosing (14 of 14 comparisons). The remaining comparisons were too few to observe any trend. Of 61 variables influential in changing base-case conclusions, effectiveness of PGx testing was the most common (37%), accounted for in the models using time-based or medication-based approaches or relative risk. The cost of PGx testing has decreased and plateaued over time. CONCLUSIONS EEs to date only partially inform decisions on selecting optimal PGx testing for AF, because most evidence focuses on PGx testing to determine coumadin dosing, but less on other purposes. Future EE may refer to the list of influential variables and the approaches used to account for the effect of PGx testing to inform data collection and study design.
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Affiliation(s)
- Ahmad Amir Kamil
- School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, England, UK
| | - Ka Keat Lim
- School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, England, UK; National Institute for Health Research Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, England, UK
| | - Rositsa Koleva-Kolarova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK
| | - Philip Chowienczyk
- National Institute for Health Research Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, England, UK; Cardiovascular Division, Department of Clinical Pharmacology, King's College London and St Thomas' Hospital Medical School, London, UK
| | - Charles D A Wolfe
- School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, England, UK; National Institute for Health Research Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, England, UK; National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, South London, England, UK
| | - Julia Fox-Rushby
- School of Life Course & Population Sciences, Faculty of Life Sciences & Medicine, King's College London, London, England, UK; National Institute for Health Research Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, England, UK.
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Hussain A, Minhas A, Sarwar U, Tahir H. Triple Antithrombotic Therapy (Triple Therapy) After Percutaneous Coronary Intervention in Chronic Anticoagulation: A Literature Review. Cureus 2022; 14:e21810. [PMID: 35261831 PMCID: PMC8893676 DOI: 10.7759/cureus.21810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 02/01/2023] Open
Abstract
Selecting anticoagulation therapy for patients with atrial fibrillation and coronary artery disease has always been challenging for physicians. The treatment modalities have evolved with time. Oral anticoagulation with warfarin was used in the initial era of stenting to prevent stent thrombosis, and dual antiplatelet therapy is the current recommendation. Triple anticoagulation therapy, i.e., aspirin, P2Y12 inhibitor, and oral anticoagulation, is associated with higher bleeding episodes and mortality compared to the combination of an anticoagulant and a P2Y12 inhibitor.
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Impact of the COVID-19 lockdown on the adherence of stroke patients to direct oral anticoagulants: a secondary analysis from the MAAESTRO study. J Neurol 2022; 269:19-25. [PMID: 34081196 PMCID: PMC8173508 DOI: 10.1007/s00415-021-10631-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/25/2021] [Accepted: 05/27/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The negative impact of the COVID-19 outbreak on stroke care has been reported, but no data exist on the influence of the lockdown on medication adherence to antithrombotic treatment for stroke prevention. We present a comparison of electronic adherence data of stroke patients treated with direct oral anticoagulants (DOAC) prior to and during the COVID-19 lockdown in spring 2020 in Switzerland. METHODS This is a secondary analysis using data from the ongoing MAAESTRO study, in which stroke patients with atrial fibrillation electronically monitor their adherence to DOAC treatment. Eligible patients for this analysis had at least four weeks of adherence data prior to and during the COVID-19 lockdown. Three adherence metrics (taking adherence, timing adherence, drug holidays) were calculated and compared descriptively. RESULTS The analysis included eight patients (median age 81.5 years, IQR 74.8-84.5). Five patients had a pre-lockdown taking adherence over 90% (mean 96.8% ± 2.9), with no change during lockdown, high timing adherence in both periods and no drug holidays. The remaining three patients had pre-lockdown taking and timing adherence below 90%. Of those, two patients showed a moderate decline either in taking or timing adherence compared to pre-lockdown. One showed a substantial increase in taking and timing adherence during lockdown (both + 25.8%). CONCLUSION Our data suggest that a major disruption of social life (i.e., the imposed COVID-19 lockdown) is unlikely to relevantly affect the medication intake behaviour of patients with high pre-established adherence, but might have an impact in patients with previously suboptimal adherence. TRIAL REGISTRATION NUMBER MAAESTRO: electronic Monitoring and improvement of Adherence to direct oral Anticoagulant treatment-a randomized crossover study of an Educational and reminder-based intervention in ischaemic STROke patients under polypharmacy, NCT03344146.
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Dsouza JP, Chakrabarty J, Ramachandran P, Guddattu V, Nayak BS, George A. Effectiveness of a Nursing Intervention Module on Adherence, Knowledge, Quality of Life, and Complications Among Patients Receiving Anticoagulation therapy-a Randomized Controlled Trial Protocol. Patient Prefer Adherence 2022; 16:1723-1731. [PMID: 35903081 PMCID: PMC9314451 DOI: 10.2147/ppa.s365585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cardiovascular diseases are one of the major causes of mortality at the global level. They account for approximately 17.9 million deaths per year. Warfarin and acenocoumarol are the commonly used oral anticoagulants to treat and prevent thromboembolic disorders in patients with cardiovascular diseases. In India, approximately 2-2.5 million patients with rheumatic heart disease are receiving oral anticoagulation therapy. Additionally, this therapy is provided for stroke prevention in the case of atrial fibrillation and the treatment of valvular heart disease, stroke, and deep vein thrombosis. As the therapeutic range of these drugs is narrow and is affected by many factors, their use is challenging. This study aims to evaluate the effectiveness of a nursing intervention module in terms of adherence to therapy, knowledge, quality of life, and complications among patients receiving oral anticoagulation therapy. Furthermore, this study will address factors that affect adherence and the risk for bleeding by using a randomized controlled trial design. METHODS This single-blind, single-center, randomized controlled trial will focus on adherence to oral anticoagulation therapy. A total of 320 patients who are on oral anticoagulation therapy will be randomized into blocks and allocated to either the intervention or standard care group. The intervention will comprise the use of a nursing intervention module that includes a booklet, log sheet, and decision aid on oral anticoagulation therapy adherence. Outcome measures, that is, knowledge regarding oral anticoagulation therapy, adherence, complications, and quality of life, will be assessed at the baseline and during follow-ups. DISCUSSION Patient safety can be best achieved through patients' adherence to medication dose and monitoring of blood test values. Thromboembolic and bleeding complications are likely to occur when either the patient does not adhere to the treatment or the therapeutic range of the international normalized ratio is not maintained. This study will assess the nonadherence behavior and the effectiveness of a nursing intervention module toward adherence behavior. TRIAL REGISTRATION This research project is registered under the Clinical Trial Registry of India (CTRI/2019/06/019610).
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Affiliation(s)
- Janet Prameela Dsouza
- Department of Medical-Surgical Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Jyothi Chakrabarty
- Department of Medical-Surgical Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Correspondence: Jyothi Chakrabarty, Professor and Head, Department of Medical-Surgical Nursing, Manipal College of Nursing Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India, Tel +91 9880078542, Email
| | - Padmakumar Ramachandran
- Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
- Padmakumar Ramachandran, Professor and Unit Head, Department of Cardiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India, Tel +91 9900921428, Email
| | - Vasudeva Guddattu
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Baby S Nayak
- Department of Child Health Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Anice George
- Department of Child Health Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Bonsu KO, Young S, Lee T, Nguyen H, Chitsike RS. Adherence to Antithrombotic Therapy for Patients Attending a Multidisciplinary Thrombosis Service in Canada - A Cross-Sectional Survey. Patient Prefer Adherence 2022; 16:1771-1780. [PMID: 35923661 PMCID: PMC9339664 DOI: 10.2147/ppa.s367105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/27/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Poor medication adherence puts patients who require antithrombotic therapy at greater risk of complications. We started a multidisciplinary Adult Outpatient Thrombosis Service in 2017 in a Canadian health authority and were interested in the level of medication adherence in the population attending. AIMS The aim of this study is to assess adherence to antithrombotic medications for patients attending a multidisciplinary Thrombosis Service. METHODS We conducted a cross-sectional survey of outpatients seen at the Thrombosis Service between 2017 and 2019 using the 12-item validated Adherence to Refills and Medications Scale (ARMS) to assess adherence to antithrombotic (anticoagulants and antiplatelet) therapy. Linear regression analysis examined the factors associated with adherence to antithrombotic therapy. RESULTS Of 1058 eligible patients, 53.2% responded to the survey. Seventeen were excluded from the analysis for missing more than 6 responses to the 12 items on the ARMS. About 55% (n = 297) were on direct oral anticoagulants (DOACs), 19% (n = 102) on warfarin, 5.0% (n = 27) on low molecular weight heparin, 3.3% (n = 18) on antiplatelet therapy and 18% (n = 96) were no longer on antithrombotic therapy. Nearly half (47%, n = 253) had taken antithrombotic therapy for 1-5 years while 28% (n = 150) and 25% (n = 137) had taken antithrombotic treatments for <1 and >5 years, respectively. Most patients (87%, n = 475) were ≥50 years and half (51%, n = 277) were male. The mean adherence score was 13.9 (SD±2.2) and 88% (n = 481) of participants were adherent to antithrombotic treatment (ARMS = 12-16). Multivariable linear regression showed that patients with post-graduate education had 0.4% lower adherence to antithrombotic therapy as compared with elementary education (β = 0.0039, p = 0.048). Patients with prior antithrombotic agent use >5 years had 0.5% lower adherence to antithrombotic treatment compared to patients with <1 year (β = 0.0047, p = 0.0244). CONCLUSION Self-reported adherence to antithrombotic therapy was high (88%) within a multidisciplinary Thrombosis Service. Patients with advanced education and prolong duration of antithrombotic therapy were more likely to have lower self-reported adherence to antithrombotic treatment.
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Affiliation(s)
- Kwadwo Osei Bonsu
- School of Pharmacy, Memorial University of Newfoundland and Labrador, St John’s, NL, A1B 3V6, Canada
- Correspondence: Kwadwo Osei Bonsu, School of Pharmacy, Memorial University of Newfoundland and Labrador, 300 Prince Philip Drive, St John’s, NL, A1B 3V6, Canada, Email
| | - Stephanie Young
- School of Pharmacy, Memorial University of Newfoundland and Labrador, St John’s, NL, A1B 3V6, Canada
- Pharmacy Program, Eastern Region Health Authority, St John’s, NL, A1B 3V6, Canada
| | - Tiffany Lee
- School of Pharmacy, Memorial University of Newfoundland and Labrador, St John’s, NL, A1B 3V6, Canada
- Pharmacy Program, Eastern Region Health Authority, St John’s, NL, A1B 3V6, Canada
| | - Hai Nguyen
- School of Pharmacy, Memorial University of Newfoundland and Labrador, St John’s, NL, A1B 3V6, Canada
| | - Rufaro S Chitsike
- Division of Medicine (Hematology), Memorial University of Newfoundland and Labrador, St John’s, NL, A1B 3V6, Canada
- Division of Hematology, Eastern Region Health Authority, St John’s, NL, A1B 3V6, Canada
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Akamine A, Nagasaki Y, Tomizawa A, Arai M, Atsuda K. Risk Factors for Non-Adherence to Medications That Affect Surgery: A Retrospective Study in Japan. Patient Prefer Adherence 2022; 16:1623-1635. [PMID: 35818372 PMCID: PMC9270897 DOI: 10.2147/ppa.s365348] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/24/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Data on risk factors for non-adherence to doctors' and pharmacists' instructions to discontinue medications prior to surgery are lacking. This study aimed to identify characteristics and risk factors for such non-adherent patients. PATIENTS AND METHODS Data (including patient age, sex, prescription medications, comorbidities, presence of roommate at home, and number of days between receiving instruction and surgery) of 887 patients who used medications affecting surgery at a university hospital from April 2017 to March 2020 were retrospectively evaluated. The primary endpoint was to investigate the rate of non-adherence and to explore independent risk factors for non-adherence (with age categorized as ≥65 [versus <65] years). Secondary endpoints included analysis of limited number of departments subgroup and a sensitivity analysis (with age categorized as ≥75 [versus <75] years) to confirm the robustness of the primary endpoint results. Independent risk factors for non-adherence were identified using logistic regression analysis. RESULTS The non-adherence rate was 11.4% (n=101/887), median age (interquartile range) at admission was 73 (70-79) years, and proportion of male patients was 81.2% (n=82). The main analysis adjusted for age ≥65 (versus <65) years showed age as a risk factor for increased non-adherence (adjusted odds ratio: 2.1, 95% confidence interval: 1.09-4.05; p=0.027). However, analyses adjusted for departments (other than urology, gynecology, and breast surgery, with a large sex bias in hospitalized patients) and for age ≥75 (versus <75) years showed no such risk. CONCLUSION Age ≥65 years was associated with a higher risk of non-adherence to medications that should be discontinued before surgery. It is important for doctors and pharmacists to ensure that patients at high risk for non-adherence are aware of the importance of adherence. Our findings may help identify patients at high risk for non-adherence to such medications.
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Affiliation(s)
- Akihiko Akamine
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Kanagawa, 252-0373, Japan
- Correspondence: Akihiko Akamine, Department of Pharmacy, Kitasato University Hospital, Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0373, Japan, Tel +81-42-778-8123, Fax +81-42-778-8650, Email
| | - Yuya Nagasaki
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Kanagawa, 252-0373, Japan
| | - Atsushi Tomizawa
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Kanagawa, 252-0373, Japan
| | - Mariko Arai
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Kanagawa, 252-0373, Japan
| | - Koichiro Atsuda
- Department of Pharmacy, Kitasato University Hospital, Sagamihara, Kanagawa, 252-0373, Japan
- Research and Education Center for Clinical Pharmacy, Division of Clinical Pharmacy, Laboratory of Pharmacy Practice and Science 1, Kitasato University School of Pharmacy, Tokyo, Japan
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Chen H, Xu X, Peng J, Ge X, Zhang J, Dong Q, Jiang X, Li P. Warfarin Adherence Among Patients with Atrial Fibrillation in Rural Area of Dongyang, China: A Questionnaire-Based Study. Patient Prefer Adherence 2022; 16:2345-2352. [PMID: 36046498 PMCID: PMC9423105 DOI: 10.2147/ppa.s374808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/19/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Adherence to warfarin is associated with improved outcome in patients with atrial fibrillation (AF), but the adherence status of patients in rural areas of China is not known. METHODS A questionnaire-based study evaluating warfarin adherence of rural residents with AF was carried out in Dongyang, China. Potentially eligible patients were screened and contacted by telephone, and their demographic characteristics were collected. Illness perception was assessed using the Brief Illness Perception Questionnaire (BIPQ), and warfarin adherence was assessed using a Chinese-version adherence scale. Univariate and multivariate analyses were conducted to identify factors associated with unsatisfactory adherence. RESULTS A total of 201 patients (male, n=99; mean age, 70.3±8.12 years) were included, among whom 95 (47.3%) patients showed good adherence and 63 (31.3%) poor adherence. Number of co-dispensed drugs (multivariate analysis: odds ratio [OR]=3.64, 95% confidence interval [CI] 1.35-9.81, p=0.011) and BIPQ score (OR=1.25, 95% CI 1.17-1.33, p<0.001) were identified as factors associated with good adherence. CONCLUSION Medical adherence to warfarin needs to improve in rural patients with AF. Efforts that can reduce the number of co-dispensed drugs and increase illness perception may improve warfarin adherence. This study may benefit future management of warfarin administration to rural patients with AF.
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Affiliation(s)
- Huadong Chen
- Department of Pharmacy, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, People’s Republic of China
- Correspondence: Huadong Chen, Department of Pharmacy, Affiliated Dongyang Hospital of Wenzhou Medical University, 60th Wuning West Road, Dongyang, People’s Republic of China, Email
| | - Xing’e Xu
- Department of Pharmacy, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, People’s Republic of China
| | - Jiren Peng
- Department of Vasculocardiology, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, People’s Republic of China
| | - Xuan Ge
- Health Management Center, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, People’s Republic of China
| | - Jing’an Zhang
- Department of Pharmacy, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, People’s Republic of China
| | - Qianqian Dong
- Department of Pharmacy, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, People’s Republic of China
| | - Xiunan Jiang
- Department of Pharmacy, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, People’s Republic of China
| | - Piaopiao Li
- Department of Pharmacy, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, People’s Republic of China
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Salmasi S, De Vera MA, Safari A, Lynd LD, Koehoorn M, Barry AR, Andrade JG, Deyell MW, Rush K, Zhao Y, Loewen P. Longitudinal Oral Anticoagulant Adherence Trajectories in Patients With Atrial Fibrillation. J Am Coll Cardiol 2021; 78:2395-2404. [PMID: 34886959 DOI: 10.1016/j.jacc.2021.09.1370] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/22/2021] [Accepted: 09/29/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Conventional adherence summary measures do not capture the dynamic nature of adherence. OBJECTIVES This study aims to characterize distinct long-term oral anticoagulant adherence trajectories and the factors associated with them in patients with atrial fibrillation. METHODS Adults with incident atrial fibrillation were identified using linked population-based administrative health data in British Columbia, Canada (1996-2019). Group-based trajectory modeling was used to model patients' 90-day proportions of days covered over time to identify distinct 5-year adherence trajectories. Multinomial regression analysis was used to assess the effect of various demographic and clinical factors on exhibiting each adherence trajectory. RESULTS The study cohort included 19,749 patients with AF (mean age: 70.6 ± 10.6 years), 56% male, mean CHA2DS2-VASc stroke risk score 2.8 ± 1.4. Group-based trajectory modeling identified 4 distinct oral anticoagulants adherence trajectories: "consistent adherence" (n = 14,631, 74% of the cohort), "rapid decline and discontinuation" (n = 2,327, 12%), "rapid decline and partial recovery" (n = 1,973, 10%), and "slow decline and discontinuation" (n = 819, 4%). Very few patient variables were found to be associated with specific adherence trajectories. CONCLUSIONS There is heterogeneity among nonadherent patients in the rate and timing of decline in their medication taking. Clinical and demographic characteristics were found to be inadequate to predict patients' adherence trajectories. Insights from this study could be used to inform the design and timing of adherence interventions, and qualitative studies may be needed to better understand the psychosocial determinants and reasons for the behaviors reflected in the identified trajectories.
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Affiliation(s)
- Shahrzad Salmasi
- Collaboration for Outcomes Research & Evaluation (CORE), University of British Columbia, Vancouver, British Columbia, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary A De Vera
- Collaboration for Outcomes Research & Evaluation (CORE), University of British Columbia, Vancouver, British Columbia, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Health Evaluation & Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada
| | - Abdollah Safari
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada; Data Analytics, Statistics and Informatics, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research & Evaluation (CORE), University of British Columbia, Vancouver, British Columbia, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Health Evaluation & Outcome Sciences, Providence Health Care Research Institute, Vancouver, British Columbia, Canada; School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mieke Koehoorn
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Arden R Barry
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason G Andrade
- Division of Cardiology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Atrial Fibrillation Clinic, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Marc W Deyell
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; UBC Center for Cardiovascular Innovation, Vancouver, British Columbia, Canada
| | - Kathy Rush
- School of Nursing, Faculty of Health and Social Development, University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Yinshan Zhao
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Loewen
- Collaboration for Outcomes Research & Evaluation (CORE), University of British Columbia, Vancouver, British Columbia, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada; UBC Center for Cardiovascular Innovation, Vancouver, British Columbia, Canada.
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Satisfaction With Oral Anticoagulants Among Patients With Atrial Fibrillation: A Prospective Observational Study. CJC Open 2021; 3:1347-1356. [PMID: 34901803 PMCID: PMC8640622 DOI: 10.1016/j.cjco.2021.06.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/22/2021] [Indexed: 11/21/2022] Open
Abstract
Background Satisfaction with treatment has been identified as an important contributing factor to adherence with oral anticoagulant (OAC) therapy in patients with atrial fibrillation (AF). We aimed to evaluate the satisfaction level of patients with AF regarding OAC use over time, using validated patient-reported outcome instruments, and to identify associated patient characteristics. Methods Participants were recruited from specialized AF clinics in Canada. Eligible AF patients who were prescribed OACs were followed for up to 2 years. Participants were interviewed via telephone every 3-4 months using a structured survey. The Treatment Satisfaction Questionnaire for Medication (TSQM II) and the Anti-Clot Treatment Scale (ACTS) were used to measure satisfaction over time. Results Among the 306 participants, satisfaction scores on the TSQM II and ACTS instruments were high. Unadjusted analyses showed significantly greater satisfaction with the burden of therapy with direct OACs (DOACs) compared to that with warfarin (small-magnitude effect) and greater satisfaction with the convenience of rivaroxaban, compared with that of all other OACs (moderate-magnitude effect). After adjustment for all other variables, vitamin K antagonist therapy was associated with greater global satisfaction than was DOAC treatment. Satisfaction with benefit and burden as measured by the ACTS scale, and global satisfaction on the TSQM II scale, tended to increase over time. Patient factors that were somewhat consistently associated with greater satisfaction were female sex and younger age. Conclusions Patients with AF were highly satisfied with their therapy, with few differences among OAC classes and individual OACs. Individual patients may or may not be more satisfied with DOAC than VKA therapy, and regardless of the OAC prescribed, the may require significant support to maintain therapy adherence.
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Tiili P, Leventis I, Kinnunen J, Svedjebäck I, Lehto M, Karagkiozi E, Sagris D, Ntaios G, Putaala J. Adherence to oral anticoagulation in ischemic stroke patients with atrial fibrillation. Ann Med 2021; 53:1613-1620. [PMID: 34498537 PMCID: PMC8439221 DOI: 10.1080/07853890.2021.1968031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/09/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants (NOAC) have superior safety and comparable efficacy profile compared to vitamin-K antagonists (VKAs), with more convenient dosing schemes. However, issues with adherence to the NOACs remain unsolved. AIMS We sought to investigate the adherence to oral anticoagulation (OAC) and baseline factors associated with poor adherence after ischaemic stroke in patients with atrial fibrillation (AF). METHODS We recruited hospitalised patients (2013-2019) from two prospective stroke registries in Larissa and Helsinki University Hospitals and invited survived patients to participate in a telephone interview. We assessed adherence with the Adherence to Refills and Medications Scale (ARMS) and defined poor adherence as a score of over 17. In addition to demographics, individual comorbidities, and stroke features, we assessed the association of CHA2DS2-VASc and SAMe-TT2R2 scores with poor adherence. RESULTS Among 396 patients (median age 75.0 years, interquartile range [IQR] 70-80; 57% men; median time from ischaemic stroke to interview 21 months [IQR 12-33]; median ARMS score 17 [IQR 17-19]), 56% of warfarin users and 44% of NOAC users reported poor adherence. In the multivariable regression model adjusted for site, sex, and age, poor adherence was independently associated with tertiary education, absence of heart failure, smoking history, use of VKA prior to index stroke, and prior ischaemic stroke. CHA2DS2-VASc and SAMe-TT2R2 scores were not associated with poor adherence. CONCLUSIONS Adherence was poor in half of AF patients who survived an ischaemic stroke. Independent patient-related factors, rather than composite scores, were associated with poor adherence in these patients.KEY MESSAGESAdherence was poor in half of the atrial fibrillation patients who survived an ischaemic stroke.Independent patient-related factors rather than composite scores were associated with poor adherence.The findings support the importance of recognising adherence support as a crucial part of holistic patient care recommended by recent AF guideline.
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Affiliation(s)
- Paula Tiili
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ioannis Leventis
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Janne Kinnunen
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ida Svedjebäck
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mika Lehto
- Lohja Hospital, Department of Internal Medicine, Helsinki, Finland
- Department of Cardiology, Helsinki University Hospital, Helsinki, Finland
| | - Efstathia Karagkiozi
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Sagris
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Leblanc K, MacGillivray J, Carroccia A, Macle L, Andrade JG. The 2020 CCS atrial fibrillation guidelines for pharmacists: Top 10 takeaways. Can Pharm J (Ott) 2021; 155:107-118. [PMID: 35300017 PMCID: PMC8922222 DOI: 10.1177/17151635211058160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/19/2021] [Accepted: 06/09/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Kori Leblanc
- University Health Network, Toronto, Ontario
- Leslie Dan Faculty of Pharmacy, University of Toronto, Ontario
| | | | | | - Laurent Macle
- Institut de Cardiologie de Montreal, Montreal, Quebec
| | - Jason G. Andrade
- Faculty of Medicine, University of British Columbia, Vancouver, BC
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Hozayen SM, Zychowski D, Benson S, Lutsey PL, Haslbauer J, Tzankov A, Kaltenborn Z, Usher M, Shah S, Tignanelli CJ, Demmer RT. Outpatient and inpatient anticoagulation therapy and the risk for hospital admission and death among COVID-19 patients. EClinicalMedicine 2021; 41:101139. [PMID: 34585129 PMCID: PMC8461367 DOI: 10.1016/j.eclinm.2021.101139] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/27/2021] [Accepted: 09/07/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state. Limited data exist informing the relationship between anticoagulation therapy and risk for COVID-19 related hospitalization and mortality. METHODS We evaluated all patients over the age of 18 diagnosed with COVID-19 in a prospective cohort study from March 4th to August 27th, 2020 among 12 hospitals and 60 clinics of M Health Fairview system (USA). We investigated the relationship between (1) 90-day anticoagulation therapy among outpatients before COVID-19 diagnosis and the risk for hospitalization and mortality and (2) Inpatient anticoagulation therapy and mortality risk. FINDINGS Of 6195 patients, 598 were immediately hospitalized and 5597 were treated as outpatients. The overall case-fatality rate was 2•8% (n = 175 deaths). Among the patients who were hospitalized, the inpatient mortality was 13%. Among the 5597 COVID-19 patients initially treated as outpatients, 160 (2.9%) were on anticoagulation and 331 were eventually hospitalized (5.9%). In a multivariable analysis, outpatient anticoagulation use was associated with a 43% reduction in risk for hospital admission, HR (95% CI = 0.57, 0.38-0.86), p = 0.007, but was not associated with mortality, HR (95% CI=0.88, 0.50 - 1.52), p = 0.64. Inpatients who were not on anticoagulation (before or after hospitalization) had an increased risk for mortality, HR (95% CI = 2.26, 1.17-4.37), p = 0.015. INTERPRETATION Outpatients with COVID-19 who were on outpatient anticoagulation at the time of diagnosis experienced a 43% reduced risk of hospitalization. Failure to initiate anticoagulation upon hospitalization or maintaining outpatient anticoagulation in hospitalized COVID-19 patients was associated with increased mortality risk. FUNDING No funding was obtained for this study.
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Key Words
- %, percentage
- (n), number
- ACEi, angiotensin-converting enzyme inhibitors
- ARBs, angiotensin receptor blockers
- Anticoagulation
- CI, confidence intervals
- CKD, chronic kidney disease
- CO2, carbon dioxide
- COPD, chronic obstructive pulmonary disease
- COVID-19
- COVID-19, coronavirus disease 2019
- D-dimer
- DIC, disseminated intravascular coagulation
- DOAC, direct oral anticoagulant
- EHR, electronic health records
- EMR, electronic medical records
- HCT, hematocrit
- HIT, heparin-induced thrombocytopenia
- HR, hazard ratio
- Hospitalization
- IPAC, inpatient anticoagulation therapy
- IRB, institutional review board
- Inpatient
- MI, prior myocardial infarction
- Mortality
- OPAC, outpatient persistent anticoagulation therapy
- Outpatient
- RDW, red blood cell distribution width
- SARS-CoV-2, severe Acute Respiratory Syndrome Coronavirus-2
- SBP, systolic blood pressure
- SBP-min, minimum systolic blood pressure
- SD, standard deviations
- SE, standard errors
- SpO2-min, minimum oxygen saturation
- T1DM, type 1 diabetes mellitus
- T2DM, type 2 diabetes mellitus
- VTE, venous thromboembolism
- WBC, white blood cell
- mg/dl, milligram per deciliter
- rt-PCR, reverse transcriptase-polymerase chain reaction
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Affiliation(s)
- Sameh M. Hozayen
- Department of Medicine, Division of General Internal Medicine, Assistant Professor of Medicine, Hospitalist, University of Minnesota, Mayo Building, 420 Delaware Street, SE, 6 Floor, Room D694, Minneapolis, MN 55455, United States
- Corresponding author.
| | - Diana Zychowski
- Department of Medical Education, University of Minnesota, United States
| | - Sydney Benson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Pamela L. Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Jasmin Haslbauer
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Switzerland
| | - Alexandar Tzankov
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Switzerland
| | - Zachary Kaltenborn
- Department of Medicine, Division of General Internal Medicine, Assistant Professor of Medicine, Hospitalist, University of Minnesota, Mayo Building, 420 Delaware Street, SE, 6 Floor, Room D694, Minneapolis, MN 55455, United States
| | - Michael Usher
- Department of Medicine, Division of General Internal Medicine, Assistant Professor of Medicine, Hospitalist, University of Minnesota, Mayo Building, 420 Delaware Street, SE, 6 Floor, Room D694, Minneapolis, MN 55455, United States
| | - Surbhi Shah
- Department of Hematology and oncology, Mayo Clinic, Arizona, United States
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN, United States
| | - Ryan T. Demmer
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
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Ingason AB, Hreinsson JP, Ágústsson AS, Lund SH, Rumba E, Pálsson DA, Reynisson IE, Guðmundsdóttir BR, Önundarson PT, Björnsson ES. Rivaroxaban Is Associated With Higher Rates of Gastrointestinal Bleeding Than Other Direct Oral Anticoagulants : A Nationwide Propensity Score-Weighted Study. Ann Intern Med 2021; 174:1493-1502. [PMID: 34633836 DOI: 10.7326/m21-1474] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) rates for direct oral anticoagulants (DOACs) and warfarin have been extensively compared. However, population-based studies comparing GIB rates among different DOACs are limited. OBJECTIVE To compare rates of GIB among apixaban, dabigatran, and rivaroxaban. DESIGN Nationwide population-based cohort study. SETTING Landspítali-The National University Hospital of Iceland and the 4 regional hospitals in Iceland. PATIENTS New users of apixaban, dabigatran, and rivaroxaban from 2014 to 2019. MEASUREMENTS Rates of GIB were compared using inverse probability weighting, Kaplan-Meier survival estimates, and Cox regression. RESULTS In total, 2157 patients receiving apixaban, 494 patients receiving dabigatran, and 3217 patients receiving rivaroxaban were compared. For all patients, rivaroxaban had higher overall rates of GIB (3.2 vs. 2.5 events per 100 person-years; hazard ratio [HR], 1.42 [95% CI, 1.04 to 1.93]) and major GIB (1.9 vs. 1.4 events per 100 person-years; HR, 1.50 [CI, 1.00 to 2.24]) compared with apixaban. Rivaroxaban also had higher GIB rates than dabigatran, with similar point estimates, although the CIs were wider and included the possibility of a null effect. When only patients with atrial fibrillation were included, rivaroxaban was associated with higher rates of overall GIB than apixaban (HR, 1.40 [CI, 1.01 to 1.94]) or dabigatran (HR, 2.04 [CI, 1.17 to 3.55]). Dabigatran was associated with lower rates of upper GIB than rivaroxaban in both analyses. LIMITATIONS Unmeasured confounding and small subgroup analyses. CONCLUSION Rivaroxaban was associated with higher GIB rates than apixaban and dabigatran regardless of treatment indication. PRIMARY FUNDING SOURCE Icelandic Centre for Research and Landspítali-The National University Hospital of Iceland.
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Affiliation(s)
- Arnar B Ingason
- Faculty of Medicine, University of Iceland and Landspítali-The National University Hospital of Iceland, Reykjavík, Iceland (A.B.I., A.S.Á., P.T.Ö., E.S.B.)
| | - Jóhann P Hreinsson
- University of Gothenburg and Sahlgrenska Academy, Gothenburg, Sweden (J.P.H.)
| | - Arnar S Ágústsson
- Faculty of Medicine, University of Iceland and Landspítali-The National University Hospital of Iceland, Reykjavík, Iceland (A.B.I., A.S.Á., P.T.Ö., E.S.B.)
| | | | - Edward Rumba
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland (E.R., D.A.P.)
| | - Daníel A Pálsson
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland (E.R., D.A.P.)
| | | | | | - Páll T Önundarson
- Faculty of Medicine, University of Iceland and Landspítali-The National University Hospital of Iceland, Reykjavík, Iceland (A.B.I., A.S.Á., P.T.Ö., E.S.B.)
| | - Einar S Björnsson
- Faculty of Medicine, University of Iceland and Landspítali-The National University Hospital of Iceland, Reykjavík, Iceland (A.B.I., A.S.Á., P.T.Ö., E.S.B.)
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50
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Vrana E, Kartas A, Samaras A, Vasdeki D, Forozidou E, Liampas E, Karvounis H, Giannakoulas G, Tzikas A. Indications for percutaneous left atrial appendage occlusion in hospitalized patients with atrial fibrillation. J Cardiovasc Med (Hagerstown) 2021; 23:176-182. [PMID: 34580251 DOI: 10.2459/jcm.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Percutaneous left atrial appendage occlusion (LAAO) is an alternative nonpharmacological therapeutic option for stroke prevention in patients with NVAF. However, no data exist on potential LAAO candidates' prevalence among 'real-world' NVAF patients. This study aimed to investigate the indications for LAAO in hospitalized patients with comorbid nonvalvular atrial fibrillation (NVAF). METHODS This is a post-hoc analysis of the MISOAC-AF (Motivational Interviewing to Support OAC-AF, ClinicalTrials.gov: NCT02941978), randomized controlled trial, which enrolled NVAF patients hospitalized for any reason in a tertiary cardiology department. In this analysis, patients with a history of major bleeding or stroke under OAC therapy were considered to have a strong indication for LAAO. RESULTS A total of 980 patients with NVAF were studied (mean age 73.9 ± 10.9 years, 54.7% men). Prior major bleeding occurred in 134 (13.7%) patients (intracranial bleeding in 1%, upper and lower gastrointestinal bleeding in 6.4 and 8.9%, respectively). A total of 58 (5.9%) patients experienced an embolic stroke while being treated using OAC. Overall, either of these events was prevalent in 173 (17.7%) patients, denoting a strong indication for LAAO. CONCLUSION Almost one out of six patients hospitalized with comorbid NVAF may be considered eligible for percutaneous LAAO for stroke prevention.Trial Identification: NCT02941978, https://clinicaltrials.gov/ct2/show/NCT02941978.
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Affiliation(s)
- Eleni Vrana
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki Department of Cardiology, Interbalkan European Medical Center, Pylaia, Thessaloniki, Greece
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