[Stroke Prevention in Patients with Atrial Fibrillation in Real Clinical Practice, Emphasis on Efficacy and Safety of Anticoagulant Therapy]

Modern Anticoagulant Therapy for Atrial Fibrillation: Patient Adherence in Clinical Practice

Aim. To assess the adherence of doctors and patients to anticoagulant therapy for atrial fibrillation (AF).

Materials and methods. An observational prospective study included 99 patients with AF at high risk of thromboembolic complications in Ryazan and Omsk. To study adherence, a questionnaire for quantitative assessment of treatment adherence ("QAA-25") was used. The questionnaire allows you to assess adherence by three main parameters separately: adherence to drug therapy, lifestyle modification and medical support. For the purposes of the study, adherence rates of less than 75% were regarded as insufficient, 75%. % or more as sufficient. To assess food preferences and determine the risk of changes in the activity of warfarin, a questionnaire of food preferences was used. The questionnaire allows you to assess the risk of alimentary increase (≥30 points) and decrease (≥60 points) of warfarin activity, as well as the overall risk of alimentary change (≥90 points) of warfarin activity in each patient, taking into account the volume and frequency of consumption of products that affect the activity of warfarin.

Results. After the first visit, 99% of respondents received anticoagulant treatment. Rivaroxaban was the leader in prescribability among anticoagulants (36.7%). About a third of respondents were prescribed apixaban by a doctor (30.6%) and dabigatran  (17.3%)  and  warfarin  (19.4%)  were prescribed almost twice as rarely as rivaroxaban. Respondents with the highest rates of adherence to drug therapy, lifestyle modification and medical support are AF patients taking apixaban. The respondents who were prescribed rivaroxaban had the lowest level of adherence to drug therapy and lifestyle modification. And the lowest level of commitment to medical support is among respondents who have been prescribed warfarin. The number of people with a sufficient level of commitment did not reach half. Only 43.9% were ready to take prescribed medications and slightly more than a third (34.7%) agreed to come to appointments for a long time. But, despite the importance of lifestyle modification in patients with AF, only 16.3% of respondents said they were ready to give up bad habits, lose weight and lead a more active lifestyle. The proportion of people with sufficient adherence to drug therapy was the smallest in the group taking rivaroxaban (25.7%). The least number of respondents with sufficient commitment to medical support in the group taking dabigatran (25%). Only one in ten patients (11.1%) taking warfarin had a sufficient level of commitment to lifestyle modification. 15% of the study participants had an increased risk of alimentary changes in the activity of warfarin.

Conclusion. Assessment of adherence to anticoagulant therapy by doctors in two regional centers (Omsk and Ryazan) showed high prescribability of preventive antithrombotic therapy, which corresponds to modern therapeutic approaches. At the same time, patients demonstrated rather low levels of adherence to drug therapy, lifestyle modification, and medical support.

Changes in Prescribing Antithrombotic Therapy in Patients with Atrial Fibrillation in the Multidisciplinary Hospital in Volgograd from 2012 to 2020

Aim. To study the frequency of prescribing antithrombotic agents in patients with non-valvular atrial fibrillation (AF) in real clinical practice, to evaluate changes of prescriptions from 2012 till 2020.

Material and methods. The medical records of inpatients (Form 003/y) with the diagnosis AF, hospitalized in the cardiological department were analyzed. According to the inclusion criteria, the patients were over 18 years of age, established diagnosis of non-valvular AF. There were two exclusion criteria: congenital and acquired valvular heart disease and prosthetic heart valves. In retrospective analysis we have included 263 case histories in 2012, 502 ones in 2016 and 524 in 2020. CHA2DS2-VASc score was used for individual stroke risk assessment in AF. The rational use of the antithrombotic therapy was evaluated according with current clinical practice guidelines at analyzing moment.

Results. During period of observation the frequency of antiplatelet therapy significantly decreased from 25,5% to 5,5% (р<0.001), decreased the frequency of administration of warfarin from 71,9% to 18,3% (р<0.001). The frequency of use of direct oral anticoagulants increased in 2020 compared to 2016 (р<0.001). For patients with a high risk of stroke anticoagulant therapy was administered in 71.8% of cases in 2012, 88.5% in 2016 and 92.5% in 2020. Before discharge from hospital majority of patients (72%) achieved a desired minimum international normalized ratio (INR) from 2.0 to 3.0 in 2012. In 2016 and 2020 an only 33% and 40.6% of patients achieved INR (2.0-3.0).

Conclusion. Doctors have become more committed to following clinical guidelines during the period of the investigation. In 2020 antithrombotic therapy for atrial fibrillation was suitable according to current clinical guidelines.

[Features of anticoagulant therapy of atrial fibrillation in combination with impaired renal function]

This review focuses on issues of anticoagulant therapy in patients with atrial fibrillation (AF) associated with chronic kidney disease (CKD). Such patients are at high risk of stroke whereas the choice of an anticoagulant is difficult. A wealth of information about a negative effect of warfarin on the kidney function has accumulated. A need for an alternative therapy to warfarin for patients with stage 3-4 CKD has become imminent. In this regard, rivaroxaban seems to be an appropriate replacement for warfarin in such patients. In randomized, controlled studies that evaluated the efficacy of direct oral anticoagulants in comparison with warfarin, the efficacy and safety profile of a "kidney" dose in moderate disorders of kidney function has been studied only for rivaroxaban. Moreover, both randomized, controlled studies and studies performed in the conditions of clinical practice, have demonstrated a more favorable effect of rivaroxaban on kidney function compared to warfarin. Patients with AF associated with CKD require a comprehensive protection, which, according to results of clinical studies, may be provided by rivaroxaban.