Stroke associated with discontinuation of warfarin therapy for atrial fibrillation

Spivey, Christina A.; Liu, Xianchen; Qiao, Yanru; Mardekian, Jack; Parker, Robert B.; Phatak, Hemant; Masseria, Cristina; Kachroo, Sumesh; Abdulsattar, Younos; Wang, Junling

doi:10.1185/03007995.2015.1082995

Cited by 28 publications

(29 citation statements)

References 21 publications

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Section: Discussionmentioning

confidence: 99%

“…35–38 Although overall adherence has not definitively been shown to be associated with stroke risk, gaps in therapy during treatment with warfarin has been shown to impart increased risk of stroke. 38 Gaps in therapy can include missed doses, as well as delays in filling subsequent prescriptions. While individual missed doses could not be assessed in these data, we observed the number of gaps for each treatment group and showed that rivaroxaban was associated with fewer gaps compared with the other treatments.…”

Section: Discussionmentioning

confidence: 99%

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Adherence to Rivaroxaban, Dabigatran, and Apixaban for Stroke Prevention for Newly Diagnosed and Treatment-Naive Atrial Fibrillation Patients: An Update Using 2013-2014 Data

Brown

Shewale

Talbert

2017

JMCP

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BACKGROUND Few studies have assessed adherence to non-vitamin K antagonist oral anticoagulants (NOACs), especially using contemporary data now that multiple NOACs are available. OBJECTIVE To compare adherence and treatment patterns among NOACs for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). METHODS Incident and treatment-naive NVAF patients were identified during 2013–2014 from a large claims database in this retrospective cohort study. Patients were included who initiated rivaroxaban, dabigatran, or apixaban within 30 days after diagnosis. Adherence to the index medication and adherence to any oral anticoagulant was assessed using the proportion of days covered (PDC) at 3, 6, and 9 months. The number of switches and gaps in therapy were also evaluated. Analyses were stratified by stroke risk scores, and a logistic regression model was used to control for factors that may predict high adherence. RESULTS Dabigatran had lower adherence (PDC = 0.76, 0.64, 0.57) compared with rivaroxaban (PDC = 0.83, 0.73, 0.66; P < 0.001) and apixaban (PDC = 0.82, 0.72, 0.66; P < 0.001) at 3, 6, and 9 months of follow-up and twice the number of switches to either other anticoagulants or antiplatelet therapy. Adherence was higher overall as stroke risk increased, and dabigatran had consistently lower adherence compared with the other NOACs. Multivariable logistic regression predicting PDC ≥ 0.80 showed rivaroxaban users with higher odds of high adherence compared with dabigatran or rivaroxaban across all time periods. Adjusted analyses showed that increasing age and comorbid hypertension and diabetes were associated with higher adherence. CONCLUSIONS In this real-world analysis of adherence to NOACs, rivaroxaban and apixaban had favorable unadjusted adherence profiles compared with dabigatran, while rivaroxaban users had higher odds of high adherence (PDC ≥ 0.80) among the NOACs in adjusted analyses. Clinicians and managed care organizations should consider the implications of lower adherence on clinical outcomes and quality assessment.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Adherence to Rivaroxaban, Dabigatran, and Apixaban for Stroke Prevention for Newly Diagnosed and Treatment-Naive Atrial Fibrillation Patients: An Update Using 2013-2014 Data

Brown

Shewale

Talbert

2017

JMCP

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“…Although DOACs are easier to use than warfarin, poor medication compliance may have a negative impact on clinical outcomes [76].…”

Section: Dabigatran Compliancementioning

confidence: 99%

“…One-year persistence rate of warfarin is nearly 50% [78], although some authors report even smaller numbers [75,76]. However, contrasting results about this crucial issue have been published, demonstrating low compliance (namely \50%) also in patients treated with DE [79].…”

Section: Dabigatran Compliancementioning

confidence: 99%

Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients

Molteni

Minno

et al. 2017

Intern Emerg Med

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Dabigatran etexilate (DE) is a direct thrombin inhibitor, which has been approved for the treatment of non-valvular atrial fibrillation (AF), and for the prevention and treatment of venous thromboembolism (VTE). Despite large randomized clinical trials and independent observational studies providing robust data concerning DE safety and efficacy, some physicians still perceive mild-to-moderate renal impairment and old age as a relative contraindication to its use. In this article, we review the available scientific evidence supporting the use of DE in these clinical situations. Patients with AF and chronic kidney disease (CKD) are per se at high risk of stroke, bleeding and mortality. Although there is evidence of clinical benefit of anticoagulation in these patients, anticoagulant therapy requires caution and demands careful clinical monitoring, regardless of the drug used. In patients with no contraindication to its use, the clinical benefit of DE versus warfarin is independent of renal function. The elderly with AF are frequently undertreated because of the perception of high bleeding risk and limited clinical benefit. However, the clinical benefit of anticoagulation is independent of patient age, and age per se should not represent a contraindication to anticoagulation. DE has been extensively studied in the elderly, both in randomized clinical trials and in observational studies: DE 150 mg BID should not be used in patients 80 years of age or older, while DE 110 mg BID is as safe as warfarin. Intracranial haemorrhages reduction by DE compared with warfarin is preserved in the elderly. Therefore, mild and moderate CKD and being elderly should not deter physicians from prescribing DE. Furthermore, the availability of a specific antidote is expected to improve the safety of the use of DE in clinical practice.

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“…Nasuprot tome, veće zadovoljstvo terapijom se izdvojilo kao multivarijantni prediktor niže verovatnoće nepovoljnih KV ishoda, odnosno ispitanici sa najvišom ocenom zadovoljstva sprovedenim lečenjem imali su upola nižu verovatnoću da dožive neki od nepovoljnih KV ishoda u udnosu na ispitanike sa najnižom ocenom. Moguće objašenjenje je da su bolesnici koji su bili zadovoljniji lečenjem ostvarili bolju terapijsku adherenciju i perzistenciju tokom narednih godinu dana, uključujući adekvatnu tromboprofilaksu, primenu antitrombocitnih i drugih KV lekova, što se povoljno odrazilo na sniženje rizika od komplikacija [27,28]. Takođe smo pokazali da je viši QoL multivarijantni prediktor nižeg rizika od simptomatske srčane slabosti, odnosno da ispitanici sa najvišim ukupnim AFEQT skorom imaju ~60% manju verovatnoću za ispoljavanje srčane insuficijencije od ispitanika sa najnižom ocenom QoL.…”

Section: Diskusijaunclassified

Assessment of the association between quality of life in patients with atrial fibrillation and cardiovascular outcomes during the one-year follow-up

Vlajkovic¹,

Vilotijevic²,

Polovina³

2017

Med podmladak

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Introduction: Research evidence indicates that atrial fibrillation (AF) could have a negative impact on the quality-of-life (QoL). AF symptom pattern and AF-related QoL have been associated with adverse cardiovascular outcomes. Aim: The aims of the present study are to evaluate AF-related impact on QoL using the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire, and to assess the association of QoL with adverse cardiovascular outcomes during the 1-year follow-up. Material and methods: An observational, cohort study that included AF patients treated at the Cardiology Clinic, Clinical Center of Serbia, willing to fill-in AFEQT questionnaire to assess the overall QoL (AFEQT score, 0 to 100) and QoL components: symptoms, daily activities, treatment concerns and treatment satisfaction. During the prospective 1-year follow-up, data on the following outcomes were collected: 1) major adverse cardiovascular outcomes -a combined endpoint, including: stroke/transient ischemic attack, myocardial infarction, percutaneous/surgical coronary revascularization, or cardiovascular death; 2) hospitalization for heart failure. Results: We included 202 AF patients (mean age: 64.5±12.4 years; 62.9% men; 24.3% asymptomatic AF). The mean AFEQT score was 64.3± 8.8. There was a negative correlation between objective estimate of AF-related symptoms and AFEQT score (Spearman rho = -0.489, P<0.001). During 1-year follow-up, major adverse cardiovascular outcomes occurred in 8.4% of patients and 3.5% were hospitalized for heart failure. In a multivariate logistic regression model, controlling for clinical variables, treatment satisfaction score was significantly associated with major adverse cardiovascular outcomes (OR, 0.97; 95%CI, P=0.022), while the overall AFEQT score was associated with heart failure hospitalizations (OR, 0.98; 95%CI, 0.95-0.99; P=0.014). Conclusion: Our results indicate that AF has a negative impact on QoL. Better QoL as assessed by AFEQT score and higher treatment satisfaction are associated with reduced odds for adverse outcomes, which is relevant for clinical risk-stratification and appropriate treatment of AF patients.

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Stroke associated with discontinuation of warfarin therapy for atrial fibrillation

Cited by 28 publications

References 21 publications

Adherence to Rivaroxaban, Dabigatran, and Apixaban for Stroke Prevention for Newly Diagnosed and Treatment-Naive Atrial Fibrillation Patients: An Update Using 2013-2014 Data

Adherence to Rivaroxaban, Dabigatran, and Apixaban for Stroke Prevention for Newly Diagnosed and Treatment-Naive Atrial Fibrillation Patients: An Update Using 2013-2014 Data

Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients

Assessment of the association between quality of life in patients with atrial fibrillation and cardiovascular outcomes during the one-year follow-up

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