Non‑persistence to Oral Anticoagulation Therapy in Elderly Patients with Non‑valvular Atrial Fibrillation

Abstract

Purpose To investigate the reasons for elderly atrial fibrillation (AF) patients not continuing their oral anticoagulation (OAC) treatment and the factors that influence this behavior. Methods Elderly AF patients (aged≥75 years) hospitalized from December 2019 to May 2022 were consecutively enrolled. Clinical, demographic, and concomitant medication data were collected. The endpoint was defined as OAC discontinuation for more than 30 days or a switch to an alternative therapy. Predictors of OAC non-persistence were investigated using a multivariable Cox regression model. Results This study included 560 participants (51.1% men, mean age 80.9±0.2 years). During a median follow-up of 20 months, medication persistence was observed in 322 patients (57.5%). Non-persistence was found to be significantly higher with warfarin than with NOAC (48.8% vs 33.6%, p = 0.006). In the multivariate analysis, OAC non-persistence was independently predicted by a history of permanent pacemaker implantation, the use of antiplatelet drugs, employee Medicare, living with children, college degree or above, and persistent AF (HR = 1.580, 1.586, 0.604, 0.668, 0.028, 0.769, p < 0.05, respectively). Treatment discontinuation within 3 months of discharge was observed in a large number of patients (81.8%). Medication discontinuation due to bleeding was more frequently observed in patients who continued for longer than 3 months (p < 0.001), while discontinuation due to patient preference was more frequent in those with shorter durations (≤3 months) (p = 0.049). Patient preference was the second leading cause of non-persistence in patients, regardless of whether they were taking warfarin or NOAC. Conclusion OAC non-persistence remains high among elderly AF patients during long-term follow-up, with a significant proportion discontinuing shortly after discharge. This pattern of non-persistence is heavily influenced by demographic factors and patient preference. Further interventions should be developed based on the reasons and risk factors to improve persistence and initiated early in the treatment process.

How to Improve Very Low Adherence to Anticoagulation Therapy in Elderly Patients with Non-Valvular Atrial Fibrillation [Letter]

“… 2 Notably, while this study reported a 30% discontinuation rate of anticoagulants, the authors’ study documented a higher termination rate of 57%. 1 Could the authors provide clarification regarding the discrepancy between their findings and those of previous studies? Previous literature has predominantly concentrated on bleeding risk during anticoagulation therapy in elderly cohorts, 2 yet the authors shed light on the pivotal aspect of patient preferences.…”

“…Cao et al undertook a comprehensive exploration into the causes behind discontinuation of oral anticoagulation treatment among elderly patients with atrial fibrillation, aiming to elucidate the factors influencing such behavior. 1 Their investigation revealed a high rate of non-adherence to oral anticoagulants among this demographic, primarily manifesting shortly after initial discharge. This behavioral pattern predominantly stemmed from demographic aspects and individual patient inclinations.…”

“…Previous literature has predominantly concentrated on bleeding risk during anticoagulation therapy in elderly cohorts, 2 yet the authors shed light on the pivotal aspect of patient preferences. 1 Might patient education contribute to ameliorating this low adherence?…”

“…One of the primary reasons for warfarin termination lay in perceiving anticoagulation therapy as excessively burdensome. 1 Dietary restrictions and frequent blood tests posed considerable inconvenience, particularly for elderly patients. When feasible, transitioning from warfarin to direct oral anticoagulants (DOACs) is recommended.…”

“…When feasible, transitioning from warfarin to direct oral anticoagulants (DOACs) is recommended. Conversely, the major impetus for DOAC cessation revolved around the exorbitant costs associated with this treatment, 1 an issue anticipated to abate with the forthcoming introduction of generic medications. Thus, can it be posited that the low adherence to anticoagulants will witness improvement in the foreseeable future?…”