Reasons for discontinuing oral anticoagulation therapy for atrial fibrillation: a systematic review

Buck, Jackie; Hill, Julia; Martin, Alison; Springate, Cassandra; Ghosh, Bikramaditya; Ashton, Rachel; Lee, Geraldine; Orlowski, A

doi:10.1093/ageing/afab024

Cited by 22 publications

(30 citation statements)

References 29 publications

(100 reference statements)

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“…Several previous studies also reported a higher rate of warfarin discontinuation compared to each DOAC [ 30 ]. This could be related to either incident bleeding events or anticipated higher risk of bleeding with warfarin or the risk of frailty in the elderly [ 31 ].…”

Section: Discussionmentioning

confidence: 99%

Oral Anticoagulant Discontinuation and Its Predictors in Patients with Atrial Fibrillation

Kefale

Bezabhe

Peterson

2022

JCM

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Background: Oral anticoagulants (OACs) are important in reducing the risk of ischaemic stroke in people with atrial fibrillation (AF). Although patients need to take their OAC continuously, it has been suggested that discontinuation is common in clinical practice, and this could predispose patients to thrombotic complications. Aims: To investigate the rate of OAC discontinuation and its predictors in patients with AF, using national data from Australian general practices. Methods: We analysed data obtained from NPS MedicineWise’s MedicineInsight dataset. We included patients with a recorded diagnosis of AF who newly started an OAC between 1 January 2013 and 31 December 2017. Patients were considered persistent if an OAC was prescribed continuously without discontinuing more than 60 days gap in therapy. The follow-up period was 12 months post-initiation. Multivariable models were used for the analysis of predictors. Results: Of 16,075 patients included in the cohort, 47.3% were females, and the mean age was 74.6 (SD 10.2) years. The overall OAC discontinuation rate was 13.2% (confidence interval (CI) 12.6–13.7%) by 12 months post-initiation. The discontinuation rates for warfarin, apixaban, dabigatran and rivaroxaban were 18.3% (95% CI 17.2–19.5%), 10.1% (95% CI 9.2–11.0%), 10.9% (95% CI 9.4–12.5%) and 12.2% (95% CI 11.4–13.2%), respectively. Warfarin had a significantly higher risk of discontinuation compared to direct-acting OACs. Factors that are known to increase the risk of stroke (older age, diabetes, and hypertension) were associated with better persistence. Conclusions: A relatively high proportion of patients with AF continued OAC therapy by 12 months post-initiation. Positively, patients with the highest risk of stroke and lowest risk of bleeds seemed to have better persistence.

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Section: Discussionmentioning

confidence: 99%

Oral Anticoagulant Discontinuation and Its Predictors in Patients with Atrial Fibrillation

Kefale

Bezabhe

Peterson

2022

JCM

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“…21 Additionally, frailty is a major factor influencing discontinuation of therapy for those already taking anticoagulants. 22 Such findings illustrate the perpetual dilemma for prescribing anticoagulation in co-existent atrial fibrillation, frailty, and risk of falls, particularly given the rising rateadjusted fall death rate as more individuals are surviving with stroke disability. 23 Frailty and the risk of stroke Frailty in stroke is common.…”

Section: Frailty and Vascular Risk Factorsmentioning

confidence: 98%

Frailty and cerebrovascular disease: Concepts and clinical implications for stroke medicine

Evans

Todd

Minhas

et al. 2021

International Journal of Stroke

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Frailty is a distinctive health state in which the ability of older people to cope with acute stressors is compromised by an increased vulnerability brought by age-associated declines in physiological reserve and function across multiple organ systems. Although closely associated with age, multimorbidity, and disability, frailty is a discrete syndrome that is associated with poorer outcomes across a range of medical conditions. However, its role in cerebrovascular disease and stroke has received limited attention. The estimated rise in the prevalence of frailty associated with changing demographics over the coming decades makes it an important issue for stroke practitioners, cerebrovascular research, clinical service provision, and stroke survivors alike. This review will consider the concept and models of frailty, how frailty is common in cerebrovascular disease, the impact of frailty on stroke risk factors, acute treatments, and rehabilitation, and considerations for future applications in both cerebrovascular clinical and research settings. â

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“…The most common outcomes reported were TTR, proportion of INR measurements in range, or PDC (a measure used for direct OACs as they do not require as frequent blood monitoring as warfarin). Adherence [50,57,59,60], persistence [52,56], discontinuation [51], and switching [58] were also reported. Most reviews assessed patients with any condition (including AF or VTE); nine reviews focussed on patients with AF; one focussed on AF or VTE; none focussed on patients with VTE.…”

Section: Self-monitoringmentioning

confidence: 98%

“…From the initial search, we identified six reviews [44][45][46][47][48][49] that addressed self-monitoring, and from the update search, a further 15 reviews [38,[50][51][52][53][54][55][56][57][58][59][60][61][62][63] that addressed self-monitoring or adherence. The summary characteristics are presented in Table 3, below.…”

Section: Self-monitoringmentioning

confidence: 99%

Oral anticoagulants: a systematic overview of reviews on efficacy and safety, genotyping, self-monitoring, and stakeholder experiences

Khouja

Brunton²,

Richardson³

et al. 2022

Syst Rev

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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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Reasons for discontinuing oral anticoagulation therapy for atrial fibrillation: a systematic review

Cited by 22 publications

References 29 publications

Oral Anticoagulant Discontinuation and Its Predictors in Patients with Atrial Fibrillation

Oral Anticoagulant Discontinuation and Its Predictors in Patients with Atrial Fibrillation

Frailty and cerebrovascular disease: Concepts and clinical implications for stroke medicine

Oral anticoagulants: a systematic overview of reviews on efficacy and safety, genotyping, self-monitoring, and stakeholder experiences

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