Adherence and Quality of Oral Anticoagulation in Cerebrovascular Disease Patients with Atrial Fibrillation

Weimar, Christian; Benemann, Jens; Katsarava, Zaza; Weber, Ralph; Diener, H. C.

doi:10.1159/000144085

Cited by 21 publications

(30 citation statements)

References 56 publications

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“…The proportion of patients nonadherent to OAC recommendation at 15 months after the index event in our study (39%) is within the range reported in previous hospital studies; previously, adherence rates between 29% (at 180 days) and 60% in clinical practice and till 90% (in one year, as a part of a phase 3 study) were reported [6,18,19,22,30]. Expectedly, adherence was lower than in clinical trials [6].…”

Section: Discussionsupporting

confidence: 87%

“…However, despite scientific evidence, a considerable proportion of patients with AF and an indication for long-term OAC remain untreated or discontinue treatment [11,19]. Risk factors associated with underuse of OAC are high age and poor functional status [17,30], but the high rate of underuse is not satisfactorily explained by these patient characteristics or by the practitioner's specialty [28]. The available survey- and primary care-based observational studies included only individuals treated as inpatients as a part of a cohort study [17,28,30].…”

Section: Introductionmentioning

confidence: 99%

“…Risk factors associated with underuse of OAC are high age and poor functional status [17,30], but the high rate of underuse is not satisfactorily explained by these patient characteristics or by the practitioner's specialty [28]. The available survey- and primary care-based observational studies included only individuals treated as inpatients as a part of a cohort study [17,28,30]. To our knowledge, no study of long-term adherence to and treatment interruptions of OAC in a consecutive cohort of patients with acute cerebrovascular events has been performed yet.…”

Section: Introductionmentioning

confidence: 99%

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Reasons Underlying Non-Adherence to and Discontinuation of Anticoagulation in Secondary Stroke Prevention among Patients with Atrial Fibrillation

Gumbinger¹,

Holstein²,

Stock³

et al. 2015

Eur Neurol

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Background: Although long-term oral anticoagulation (OAC) with vitamin K antagonists for secondary stroke prevention in atrial fibrillation (AF) is highly effective, it is frequently not started or discontinued in clinical practice. We analyzed the reasons for stroke patients' and physician's nonadherence. Methods: In this prospective, observational, single-center cohort study, consecutive patients diagnosed with acute ischemic stroke or transient ischemic attack (TIA) and AF presenting during a nine-month period were included. Adherence to OAC was evaluated at 15 ± 1 months after the event using a semi-structured telephone interview. In patients without anticoagulation, the primary care physician (PCP) was contacted to explore the reason. Associations between nonadherence to OAC therapy at follow-up and potential predictors were assessed by logistic regression analysis. Results: Of the 1,049 presenting stroke/TIA patients, 139 with a first (n = 101) or a continued recommendation (n = 38) of OAC were analyzed. After 15 months, 54 patients (39% of 85 patients with OAC at follow-up) were nonadherent. The main reasons for patients' nonadherence were fear of side effects (e.g., bleeding) and inconvenience of regular international normalized ratio measurements. In two-thirds (36/54) of cases, OAC was not prescribed by the PCP; the most important reasons were a putative high risk of falling and dementia. Risk factors for nonadherence were dementia, living in a nursing home, and the noninitiation of OAC during in-hospital stay. Treatment was temporarily discontinued in 21 (25%) of patients on OAC at follow-up. Conclusion: Nonadherence to OAC in stroke patients results from fear of potential complications or inconvenience and physicians' concerns regarding functional status. OAC should be initiated wherever possible during the in-hospital stay.

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Section: Discussionsupporting

confidence: 87%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Reasons Underlying Non-Adherence to and Discontinuation of Anticoagulation in Secondary Stroke Prevention among Patients with Atrial Fibrillation

Gumbinger¹,

Holstein²,

Stock³

et al. 2015

Eur Neurol

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“…It should be noted that only 30.5% of patients with atrial fibrillation received anticoagulant prophylaxis in a recent German study. 16 GWTG-Stroke performance on this stroke prevention measure offers another global standard to countries like Taiwan and Germany.…”

Section: Discussionmentioning

confidence: 99%

Get With The Guidelines-Stroke Performance Indicators: Surveillance of Stroke Care in the Taiwan Stroke Registry

et al. 2010

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the Taiwan Stroke Registry InvestigatorsBackground-Stroke is a leading cause of death around the world. Improving the quality of stroke care is a global priority, despite the diverse healthcare economies across nations. The American Heart Association/American Stroke Association Get With the Guidelines-Stroke program (GWTG-Stroke) has improved the quality of stroke care in 790 US academic and community hospitals, with broad implications for the rest of the country. The generalizability of GWTG-Stroke across national and economic boundaries remains to be tested. 2,3 This was followed by the implementation of the American Heart Association/American Stroke Association Get With the Guidelines-Stroke program (GWTG-Stroke). 4 GWTG-Stroke was the first large-scale nationwide assessment of the quality of stroke care based on a set of predefined performance measures. The 790 participating hospitals showed substantial and sustained improve- Clinical Perspective on p 1123Stroke is the second leading cause of death globally, 5 with nations with diverse health care systems facing a similar medical and economic burden. 6 Whether the successful GWTG-Stroke is applicable beyond the United States remains to be tested. A key determinant that may hamper broad application of GWTG-Stroke around the world is the diversity of healthcare economies. It could be difficult for nations spending substantially less in healthcare dollars to apply GWTG-Stroke standards. To examine whether GWTGStroke is workable across nations with substantial disparities in health expenditures, we applied GWTG-Stroke to assess the quality of stroke care in Taiwan. Like the United States, stroke is the third leading cause of death in Taiwan. In 2008, the total cost of stroke in the United States, with 780 000 new or recurrent stroke cases, was estimated to be $65.5 billion, with direct (medical) costs constituting two thirds or $43.6 billion. 5 Taiwan, with a population of 23 million (1/13 of that of the United States), with Ϸ80 000 new or recurrent strokes a year, spent a total of US $375 million in medical costs for stroke in 2007. 7 The total medical costs per new or recurrent stroke patient were Ϸ1/10 of those spent in the United States. 5 The Taiwan Stroke Registry (TSR) is an appropriate program to assess the generalizability of GWTG-Stroke across national as well as economic boundaries. TSR, sponsored by the Department of Health (DOH), was launched in 2006. With the exception of anticoagulation for deep vein thrombosis (DVT) and measures for smoking cessation, all the parameters adapted by GWTG-Stroke for assessing quality of stroke care have been included in TSR. Methods TSR Design and the Criteria for Hospital SelectionTSR is the first nationwide effort in Taiwan to establish a reliable national stroke database for assessing the quality of stroke care and identifying areas that require improvement. TSR was designed and a TSR operation manual developed after a series of consensus conferences attended by an expert panel (16 stroke neurologists and 2 epi...

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“…Rates of adherence to OAC 1 year after stroke ranged from 78 to 89% in previous studies [9,10] exceeding those in primary prevention [11]. Nevertheless, cognitive impairment, a frequent comorbidity in the elderly may challenge adequate OAC.…”

Section: Introductionmentioning

confidence: 99%

Cognitive Impairment Is Not a Predictor of Failure to Adhere to Anticoagulation of Stroke Patients with Atrial Fibrillation

Horstmann¹,

Rizos²,

Saribas³

et al. 2015

Cerebrovasc Dis

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Background: Oral anticoagulation (OAC) with vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC) is an effective strategy that is used for stroke prevention in patients with atrial fibrillation (AF). However, OAC is underused particularly in elderly patients, who are often physically disabled or cognitively impaired. We aimed at evaluating the effect of cognitive status and disability on OAC adherence 1 year after stroke or TIA. Methods: In this prospective, single-center, observational study patients with ischemic stroke or TIA were consecutively included between 3/2011 and 9/2012. The detailed medical history, basic demographic variables, cardiovascular risk factors, stroke severity according to the National Institutes of Health Stroke Scale (NIHSS), medication including OAC were all recorded. Cognitive performance was measured using the Montreal Cognitive Assessment (MoCA) score at baseline. The functional status was assessed by recording activities and instrumental activities of daily living, respectively (ADL, IADL). After 12 months, patients had a follow-up visit to reassess the cognitive and functional status (MoCA, ADL and IADL) and to document the current use of OAC. Results: In total, 12 months after the ischemic stroke or TIA AF had been diagnosed in 160/586 (27.3%). Of these, 151 patients (94.4%) were treated with OAC. OAC was performed using VKA in 79/151 (52.3%) and DOACs in 72/151 (47.7%). Cognitive impairment at 12 months follow-up was not associated with the absence of OAC treatment. However, regression analysis revealed that patients with AF with physical (ADL) and functional disability (IADL) were less likely to be treated with OAC (p = 0.08 and p = 0.04, respectively) 12 months after a stroke. None of these two factors, however, was independently associated with nonadherence to OAC 12 months after stroke. Although cognitive performance was similar in patients receiving VKA and direct anticoagulants (DOAC), adherence to VKA tended to be lower (82.6 vs. 94.6%, p = 0.12). Conclusions: In stroke and TIA patients with AF, the multifactorial medical and functional constellation rather than cognitive impairment specifically can be an obstacle for long-term OAC.

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Adherence and Quality of Oral Anticoagulation in Cerebrovascular Disease Patients with Atrial Fibrillation

Cited by 21 publications

References 56 publications

Reasons Underlying Non-Adherence to and Discontinuation of Anticoagulation in Secondary Stroke Prevention among Patients with Atrial Fibrillation

Reasons Underlying Non-Adherence to and Discontinuation of Anticoagulation in Secondary Stroke Prevention among Patients with Atrial Fibrillation

Get With The Guidelines-Stroke Performance Indicators: Surveillance of Stroke Care in the Taiwan Stroke Registry

Cognitive Impairment Is Not a Predictor of Failure to Adhere to Anticoagulation of Stroke Patients with Atrial Fibrillation

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