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Álvaro Thomsen T, Mesa Guadalupe J, Huerta C, de Burgos A, Cea Soriano L. Risk of ischemic stroke associated with direct oral anticoagulants discontinuation on patients with non-valvular atrial fibrillation. Pharmacoepidemiol Drug Saf 2024; 33:e5733. [PMID: 38011912 DOI: 10.1002/pds.5733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 10/04/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023]
Abstract
INTRODUCTION Although direct oral anticoagulants' (DOACs) prescriptions have experienced immense growth in the last decade, the proportion of discontinuers is still common yielding an increased risk of ischemic stroke (IS) onset. AIMS We aimed to estimate the association between DOACs discontinuation and risk of IS among patients with non-valvular atrial fibrillation (NVAF). METHODS We used data from a cohort of new DOACs users, followed patients from the first DOAC prescription date up to IS (index date) and conducted a nested case-control analysis using conditional logistic regression. Adjusted odds ratios, 95% confidence intervals were calculated for discontinuation of DOACs (current use compared with past use). The latter, subdivided among those stopping treatment 3 to 2 months and 6 and 3 months prior to index date. The effect of naïve current users against IS onset compared with non-naïve current users was also evaluated. RESULTS DOACs discontinuation showed an OR of IS of 1.47 (95% CI: 1.02-2.12); estimates were 2.51 (95% CI: 1.84-3.42) for whom discontinued treatment within months 3 and 2 and 1.43 (95% CI: 0.96-2.13) for those between months 6 and 3 prior to index date. Analyzing DOACs individually, risk of IS associated with past users compared with current users: 1.98 (95% CI: 1.25-3.12) for apixaban, 1.38 (95% CI: 0.40-4.72) for edoxaban, 1.98 (95% CI: 1.24-2.65) for dabigatran and 1.87 (95% CI: 1.26-2.76) for rivaroxaban. Similar results were found when stratified by naïve and non-naïve users. CONCLUSIONS DOACs' discontinuation is associated with higher risk of IS, especially in the second and third months following interruption.
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Affiliation(s)
- T Álvaro Thomsen
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - J Mesa Guadalupe
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - C Huerta
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - A de Burgos
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
- BIFAP, Division of Pharmacoepidemiology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - L Cea Soriano
- Department of Public Health and Maternal Child Health, Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
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Ashburner JM, Chang Y, Borowsky LH, Khurshid S, McManus DD, Ellinor PT, Lubitz SA, Singer DE, Atlas SJ. Effect of clinic-based single-lead electrocardiogram rhythm assessment on oral anticoagulation prescriptions in patients with previously diagnosed atrial fibrillation. Heart Rhythm O2 2023; 4:469-477. [PMID: 37645259 PMCID: PMC10461197 DOI: 10.1016/j.hroo.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
Background Despite benefits of oral anticoagulation (OAC), many individuals with diagnosed atrial fibrillation (AF) do not receive OAC. Objective The purpose of this study was to assess whether cardiac rhythm assessment for AF impacted use of OAC in patients with previously diagnosed AF. Methods VITAL-AF was a cluster randomized controlled trial conducted in 16 primary care practices assessing the efficacy of AF rhythm assessment with single-lead electrocardiogram in routine care. Patients 65 years and older were offered rhythm assessment at visits. In this secondary analysis, we evaluated rhythm assessment uptake and compared initiation and discontinuation of OAC in patients with previously diagnosed AF from intervention and control arms over 1 year. Results The study included 4593 patients with previously diagnosed AF (2250 intervention; 2343 control). In the intervention arm, 2022 (89.9%) completed rhythm assessment (median 2 visits with rhythm assessment) and 40.1% had ≥1 "Possible AF" result. Initiation of OAC was similar in the intervention (17.7%) and control (19.1%) arms but was influenced by the rhythm assessment result: higher with a "Possible AF" (26.1%; adjusted odds ratio [aOR] 1.62; 95% confidence interval [CI] 1.04-2.51), and lower with a "Normal" result (9.9%; aOR 0.45; 95% CI 0.29-0.71) compared to control. OAC discontinuation was similar in the intervention (6.3%) and control (7.2%) arms, with lower discontinuation with a "Possible AF" result (3.8%; aOR 0.51; 95% CI 0.32-0.81). Conclusions Including patients with previously diagnosed AF in a point-of-care rhythm assessment strategy did not increase overall OAC use compared to the control arm. However, the rhythm assessment result influenced both initiation and discontinuation of OAC.
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Affiliation(s)
- Jeffrey M. Ashburner
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Leila H. Borowsky
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Shaan Khurshid
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - David D. McManus
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Patrick T. Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Steven A. Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Kefale AT, Bezabhe WM, Peterson GM. Clinical outcomes of oral anticoagulant discontinuation in atrial fibrillation: a systematic review and meta-analysis. Expert Rev Clin Pharmacol 2023; 16:677-684. [PMID: 37309076 DOI: 10.1080/17512433.2023.2223973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/05/2023] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Oral anticoagulants (OACs) should generally be continued lifelong in patients with atrial fibrillation (AF) to ensure optimal benefits, unless contraindications arise. However, discontinuation of OACs might occur for various reasons, potentially affecting clinical outcomes. In this review, we synthesized evidence on the clinical outcomes following OAC discontinuation in patients with AF. METHODS We conducted a systematic review and meta-analysis using PubMed, Embase and Scopus. Cohort or case-control studies were included if data were available on clinical outcomes of OAC discontinuation, compared with continuation, in patients with AF. A random-effect meta-analyses were conducted for key outcomes of stroke, mortality, and major bleeding. RESULTS Eighteen observational studies having a total of 283,418 patients were included. Discontinuation significantly increased the risk of stroke (hazard ratio [HR] 1.88; 95% confidence interval [CI] 1.58-2.23), all-cause (HR 1.90; 95% CI 1.40-2.59) and cardiovascular (HR 1.83; 95% CI 1.06-3.18) mortality. The risk of major bleeding was not significantly different between the discontinued and continued groups (HR 1.04; 95% CI 0.72-1.52). CONCLUSIONS Discontinuation of OAC therapy was associated with an increased risk of stroke and mortality, with no difference in the risk of major bleeding. Acknowledging heterogeneity among the studies, the findings underline the need to ensure continuity of OAC therapy in patients with AF to prevent thrombotic complications and associated mortality. PROSPERO REGISTRATION NUMBER CRD42020186116.
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Affiliation(s)
- Adane Teshome Kefale
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Gregory M Peterson
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, Tasmania, Australia
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Fomicheva AV, Troshina DV, Simonov AN, Kopylov PI, Andreev DA, Volel BA. [Impact of anxiety disorders on adherence to anticoagulant therapy in patients with atrial fibrillation]. TERAPEVT ARKH 2022; 94:1085-1093. [PMID: 36286760 DOI: 10.26442/00403660.2022.09.201891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 06/16/2023]
Abstract
AIM To evaluate the impact of anxiety disorders on adherence to anticoagulant therapy (ACT) in patients with atrial fibrillation (AF). MATERIALS AND METHODS 179 outpatients (131 women, 48 men, mean age 69.96.2 years) with AF were examined. The research methods included a physical examination according to the standards of medical care in an outpatient facility, clinical and psychopathological examination using psychometric scales. RESULTS Based on the assessment of adherence to ACT using the MoriskyGreen test, 2 groups of patients were identified: Group 1 patients with high adherence to ACT, Group 2 patients with partial/low adherence to ACT. In group 1, anxiety disorders were verified in 51.7% of cases, in group 2 54.3%. There were no statistically significant differences in the prevalence and severity of anxiety in the study groups. In accordance with the binary logistic regression model, the probability of high adherence to therapy is determined by higher (compared with the group of patients with partial/low adherence to therapy) scores in terms of mental health (p0.001), vital activity (p=0.02) and the total score of the SF-36 scale (p=0.08), as well as the extraversion parameter (p=0.02) of the NEO-FFI scale. CONCLUSION In the present study, no significant association was found between anxiety symptoms and a decrease in adherence to ACT in patients with AF. However, the results obtained suggest a contribution to the adherence to therapy of personality characteristics.
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Affiliation(s)
- A V Fomicheva
- Sechenov First Moscow State Medical University (Sechenov University)
| | - D V Troshina
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | - P I Kopylov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - D A Andreev
- Sechenov First Moscow State Medical University (Sechenov University)
| | - B A Volel
- Sechenov First Moscow State Medical University (Sechenov University)
- Mental Health Research Center
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Yang M, Cheng H, Wang X, Ouyang M, Shajahan S, Carcel C, Anderson C, Kristoffersen ES, Lin Y, Sandset EC, Wang X, Yang J. Antithrombotics prescription and adherence among stroke survivors: A systematic review and meta-analysis. Brain Behav 2022; 12:e2752. [PMID: 36067030 PMCID: PMC9575604 DOI: 10.1002/brb3.2752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/09/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES We aimed to investigate the prescription of antithrombotic drugs (including anticoagulants and antiplatelets) and medication adherence after stroke. METHODS We performed a systematic literature search across MEDLINE and Embase, from January 1, 2015, to February 17, 2022, to identify studies reporting antithrombotic medications (anticoagulants and antiplatelets) post stroke. Two people independently identified reports to include, extracted data, and assessed the quality of included studies according to the Newcastle-Ottawa scale. Where possible, data were pooled using random-effects meta-analysis. RESULTS We included 453,625 stroke patients from 46 studies. The pooled proportion of prescribed antiplatelets and anticoagulants among patients with atrial fibrillation (AF) was 62% (95% CI: 57%-68%), and 68% (95% CI: 58%-79%), respectively. The pooled proportion of patients who were treated according to the recommendation of guidelines of antithrombotic medications from four studies was 67% (95% CI: 41%-93%). It was reported that 11% (95% CI: 2%-19%) of patients did not receive antithrombotic medications. Good adherence to antiplatelet, anticoagulant, and antithrombotic medications was 78% (95% CI: 67%-89%), 71% (95% CI: 57%-84%), and 73% (95% CI: 59%-86%), respectively. CONCLUSION In conclusion, we found that less than 70% of patients were prescribed and treated according to the recommended guidelines of antithrombotic medications, and good adherence to antithrombotic medications is only 73%. Prescription rate and good adherence to antithrombotic medications still need to be improved among stroke survivors.
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Affiliation(s)
- Min Yang
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Hang Cheng
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, NSW, Australia
| | - Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, NSW, Australia
| | - Sultana Shajahan
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, NSW, Australia
| | - Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, The University of Sydney, NSW, Australia
| | - Craig Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, NSW, Australia.,Department of Neurology, Royal Prince Alfred Hospital, The University of Sydney, NSW, Australia.,The George Institute China at Peking University Health Science Centre, Beijing, PR China
| | - Espen Saxhaug Kristoffersen
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway.,Department of General Practice, Helsam, University of Oslo, Oslo, Norway
| | - Yapeng Lin
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China.,International Clinical Research Center, Chengdu Medical College, Chengdu, China
| | - Else Charlotte Sandset
- Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway.,The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Xiaoyun Wang
- Department of Neurology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Jie Yang
- Department of Neurology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
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Vora P, Morgan Stewart H, Russell B, Asiimwe A, Brobert G. Time Trends and Treatment Pathways in Prescribing Individual Oral Anticoagulants in Patients with Nonvalvular Atrial Fibrillation: An Observational Study of More than Three Million Patients from Europe and the United States. Int J Clin Pract 2022; 2022:6707985. [PMID: 35685531 PMCID: PMC9159118 DOI: 10.1155/2022/6707985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 12/04/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Data directly comparing trends in the use of different oral anticoagulants (OACs) among patients with atrial fibrillation (AF) from different countries are limited. We addressed this using a large-scale network cohort study in the United States (US), Belgium, France, Germany, and the United Kingdom (UK). METHODS We used nine databases (claims or electronic health records) that had been converted into the Observational Medical Outcomes Partnership Common Data Model with analysis performed using open-source analytical tools. We identified adults with AF and a first OAC prescription, either vitamin K antagonist (VKA) or direct oral anticoagulant (DOAC), from 2010 to 2017. We described time trends in use, continuation, and switching. RESULTS In 2010, 87.5%-99.8% of patients started on a VKA. By 2017, the majority started on a DOAC: 87.0% (US), 88.3% (Belgium), 93.1% (France), 88.4% (Germany), and 86.1%-86.7% (UK). In the UK, DOACs became the most common starting OAC in 2015, 2-3 years later than elsewhere. Apixaban was the most common starting OAC by 2017, 50.2%-57.8% (US), 31.4% (Belgium), 45.9% (France), 39.5% (Germany), and 49.8%-50.5% (UK), followed by rivaroxaban, 24.8%-32.5% (US), 25.7% (Belgium), 38.4% (France), 24.9% (Germany), and 30.2%-31.2% (UK). Long-term treatment was less common in the US than in Europe, especially the UK. A minority of patients switched from their index OAC in the short and long term. CONCLUSIONS From 2010 to 2017, VKA use had significantly declined and DOAC use had significantly increased in the US and Europe. Apixaban was the most prescribed OAC in 2017, followed by rivaroxaban.
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García Rodríguez LA, Cea Soriano L, Munk Hald S, Hallas J, Balabanova Y, Brobert G, Vora P, Sharma M, Gaist D. Discontinuation of oral anticoagulation in atrial fibrillation and risk of ischaemic stroke. Heart 2020; 107:heartjnl-2020-317887. [PMID: 33310887 PMCID: PMC7958105 DOI: 10.1136/heartjnl-2020-317887] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate associations between oral anticoagulant (OAC) discontinuation and risk of ischaemic stroke (IS) among patients with atrial fibrillation (AF). METHODS We undertook a population-based cohort study with nested case-control analysis using UK primary care electronic health records (IQVIA Medical Research Data-UK) and linked registries from the Region of Southern Denmark (RSD). Patients with AF (76 882 UK, 41 526 RSD) were followed to identify incident IS cases during 2016-2018. Incident IS cases were matched by age and sex to controls. Adjusted ORs for OAC discontinuation (vs current OAC use) were calculated using logistic regression. RESULTS We identified 616 incident IS cases in the UK and 643 in the RSD. ORs for IS with any OAC discontinuation were 2.99 (95% CI 2.31 to 3.86, UK) and 2.30 (95% CI 1.79 to 2.95, RSD), for vitamin K antagonist discontinuation they were 2.38 (95% CI 1.72 to 3.30, UK) and 1.83 (95% CI 1.34 to 2.49, RSD), and for non-vitamin K antagonist oral anticoagulant discontinuation they were 4.59 (95% CI 2.97 to 7.08, UK) and 3.37 (95% CI 2.35 to 4.85, RSD). ORs were unaffected by time since discontinuation and duration of use. Annually, up to 987 IS cases in the UK and 132 in Denmark could be preventable if OAC therapy is not discontinued. CONCLUSIONS Our results suggest that patients with AF who discontinue OAC therapy have a significant twofold to threefold higher risk of IS compared with those who continue therapy. Addressing OAC discontinuation could potentially result in a significant reduction in AF-attributed IS.
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Affiliation(s)
| | | | | | | | | | | | | | - Mike Sharma
- McMaster University, Hamilton, Ontario, Canada
| | - David Gaist
- University of Southern Denmark, Odense, Denmark
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Carnicelli AP, Al-Khatib SM, Xavier D, Dalgaard F, Merrill PD, Wojdyla DM, Lewis BS, Hanna M, Alexander JH, Lopes RD, Wallentin L, Granger CB. Premature permanent discontinuation of apixaban or warfarin in patients with atrial fibrillation. Heart 2020; 107:713-720. [PMID: 32938772 DOI: 10.1136/heartjnl-2020-317229] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/21/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS The ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial randomised patients with atrial fibrillation at risk of stroke to apixaban or warfarin. We sought to describe patients from ARISTOTLE who prematurely permanently discontinued study drug. METHODS/RESULTS We performed a posthoc analysis of patients from ARISTOTLE who prematurely permanently discontinued study drug during the study or follow-up period. Discontinuation rates and reasons for discontinuation were described. Death, thromboembolism (stroke, transient ischaemic attack, systemic embolism), myocardial infarction and major bleeding rates were stratified by ≤30 days or >30 days after discontinuation. A total of 4063/18 140 (22.4%) patients discontinued study drug at a median of 7.3 (2.2, 15.2) months after randomisation. Patients with discontinuation were more likely to be female and had a higher prevalence of cardiovascular disease, diabetes, renal impairment and anaemia. Premature permanent discontinuation was more common in those randomised to warfarin than apixaban (23.4% vs 21.4%; p=0.002). The most common reasons for discontinuation were patient request (46.1%) and adverse event (34.9%), with no significant difference between treatment groups. The cumulative incidence of clinical events ≤30 days after premature permanent discontinuation for all-cause death, thromboembolism, myocardial infarction, and major bleeding was 5.8%, 2.6%, 0.9%, and 3.0%, respectively. No significant difference was seen between treatment groups with respect to clinical outcomes after discontinuation. CONCLUSION Premature permanent discontinuation of study drug in ARISTOTLE was common, less frequent in patients receiving apixaban than warfarin and was followed by high 30-day rates of death, thromboembolism and major bleeding. Initiatives are needed to reduce discontinuation of oral anticoagulation.
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Affiliation(s)
| | | | - Denis Xavier
- St John's Medical College, Bangalore, Karnataka, India
| | | | - Peter D Merrill
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | | | - Michael Hanna
- Bristol-Myers Squibb Pharmaceutical Research and Development, Princeton, New Jersey, USA
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Lars Wallentin
- Uppsala Clinical Research Center, University of Uppsala, Uppsala, Sweden
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Chu G, Seelig J, Trinks-Roerdink EM, van Alem AP, Alings M, van den Bemt B, Boersma LV, Brouwer MA, Cannegieter SC, Ten Cate H, Kirchhof CJ, Crijns HJ, van Dijk EJ, Elvan A, van Gelder IC, de Groot JR, den Hartog FR, de Jong JS, de Jong S, Klok FA, Lenderink T, Luermans JG, Meeder JG, Pisters R, Polak P, Rienstra M, Smeets F, Tahapary GJ, Theunissen L, Tieleman RG, Trines SA, van der Voort P, Geersing GJ, Rutten FH, Hemels ME, Huisman MV. Design and rationale of DUTCH-AF: a prospective nationwide registry programme and observational study on long-term oral antithrombotic treatment in patients with atrial fibrillation. BMJ Open 2020; 10:e036220. [PMID: 32843516 PMCID: PMC7449286 DOI: 10.1136/bmjopen-2019-036220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Anticoagulation therapy is pivotal in the management of stroke prevention in atrial fibrillation (AF). Prospective registries, containing longitudinal data are lacking with detailed information on anticoagulant therapy, treatment adherence and AF-related adverse events in practice-based patient cohorts, in particular for non-vitamin K oral anticoagulants (NOAC). With the creation of DUTCH-AF, a nationwide longitudinal AF registry, we aim to provide clinical data and answer questions on the (anticoagulant) management over time and of the clinical course of patients with newly diagnosed AF in routine clinical care. Within DUTCH-AF, our current aim is to assess the effect of non-adherence and non-persistence of anticoagulation therapy on clinical adverse events (eg, bleeding and stroke), to determine predictors for such inadequate anticoagulant treatment, and to validate and refine bleeding prediction models. With DUTCH-AF, we provide the basis for a continuing nationwide AF registry, which will facilitate subsequent research, including future registry-based clinical trials. METHODS AND ANALYSIS The DUTCH-AF registry is a nationwide, prospective registry of patients with newly diagnosed 'non-valvular' AF. Patients will be enrolled from primary, secondary and tertiary care practices across the Netherlands. A target of 6000 patients for this initial cohort will be followed for at least 2 years. Data on thromboembolic and bleeding events, changes in antithrombotic therapy and hospital admissions will be registered. Pharmacy-dispensing data will be obtained to calculate parameters of adherence and persistence to anticoagulant treatment, which will be linked to AF-related outcomes such as ischaemic stroke and major bleeding. In a subset of patients, anticoagulation adherence and beliefs about drugs will be assessed by questionnaire. ETHICS AND DISSEMINATION This study protocol was approved as exempt for formal review according to Dutch law by the Medical Ethics Committee of the Leiden University Medical Centre, Leiden, the Netherlands. Results will be disseminated by publications in peer-reviewed journals and presentations at scientific congresses. TRIAL REGISTRATION NUMBER Trial NL7467, NTR7706 (https://www.trialregister.nl/trial/7464).
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Affiliation(s)
- Gordon Chu
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jaap Seelig
- Department of Cardiology, Rijnstate, Arnhem, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Emmy M Trinks-Roerdink
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anouk P van Alem
- Department of Cardiology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Marco Alings
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - Bart van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lucas Va Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marc A Brouwer
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expert Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Harry Jgm Crijns
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Ewoud J van Dijk
- Deparment of Neurology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Arif Elvan
- Department of Cardiology, Isala Heart Centre, Isala Hospitals, Zwolle, Netherlands
| | - Isabelle C van Gelder
- Department of Cardiology, University Medical Centre Groningen, Groningen, Netherlands
| | - Joris R de Groot
- Department of Cardiology, Heart Centre, Amsterdam University Medical Centre/University of Amsterdam, Amsterdam, Netherlands
| | | | - Jonas Ssg de Jong
- Department of Cardiology, Heart Centre, OLVG, Amsterdam, Netherlands
| | - Sylvie de Jong
- Department of Cardiology, Elkerliek Hospital, Helmond, Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Timo Lenderink
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, Netherlands
| | - Justin G Luermans
- Department of Cardiology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Joan G Meeder
- Department of Cardiology, VieCuri Medical Centre Noord-Limburg, Venlo, Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate, Arnhem, The Netherlands
| | - Peter Polak
- Department of Cardiology, St. Anna Hospital, Geldrop, Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Centre Groningen, Groningen, Netherlands
| | - Frans Smeets
- Department of Cardiology, Hospital Bernhoven, Uden, Netherlands
| | | | - Luc Theunissen
- Department of Cardiology, Maxima Medical Centre, Eindhoven, Netherlands
| | | | - Serge A Trines
- Department of Cardiology, Heart-Lung Centre, Leiden University Medical Centre, Leiden, Netherlands
| | | | - Geert-Jan Geersing
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martin Ew Hemels
- Department of Cardiology, Rijnstate, Arnhem, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
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10
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Shehab A, Bhagavathula AS, Abebe TB, Abegaz TM, Elnour AA, Sabbour HM, Uzzafer M, Hersi A, Hamad AK. Patient Adherence to Novel Oral Anticoagulants (NOACs) for the Treatment of Atrial Fibrillation and Occurrence of Associated Bleeding Events: A Systematic Review and Meta-analysis. Curr Vasc Pharmacol 2020; 17:341-349. [PMID: 29359674 DOI: 10.2174/1570161116666180123111949] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 01/15/2018] [Accepted: 01/15/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Real-world evidence from published observational studies of adherence to Novel Oral Anticoagulants (NOACs) medications and associated clinical outcome events in Atrial Fibrillation (AF) patients, was reviewed systematically. METHODS Observational studies assessing patient adherence to NOACs conducted on AF patients between September 2010 and June 2016 were identified by systematic searching keywords to locate eligible studies, in accordance with Cochrane guidelines. PubMed, Scopus and Google Scholar databases were searched to identify the studies. Meta-analysis was performed using a random effects model with DerSimonian-Laird weighting to obtain pooled effect sizes. RESULTS From 185 potentially relevant citations, 6 studies, comprising 1.6 million AF patients, were included. Among these, successful adherence to NOACs occurred in 75.6%. Adherence levels were higher in patients treated with dabigatran (72.7%) compared with those treated with apixaban (59.9%) or rivaroxaban (59.3%). However, adherence was still suboptimal (relative to an expected 80% adherence rate). Bleeding events in non-adherent patients were found to be 7.5%. CONCLUSION Suboptimal adherence to NOACs among AF patients was highlighted as a significant risk factor that may affect clinical outcomes, with a higher percentage of non-adherent patients having bleeding events. There is an urgent need for research on the effects of specific interventions to improve patient adherence to NOACs and to assess the related outcome factors that may be associated with adherence.
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Affiliation(s)
- Abdulla Shehab
- Department of Internal Medicine, United Arab Emirates University, College of Medicine and Health Sciences, Al Ain, United Arab Emirates
| | - Akshaya S Bhagavathula
- Department of Clinical Pharmacy, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Tamrat B Abebe
- Department of Clinical Pharmacy, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia.,Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institute, Solna, Sweden
| | - Tadesse M Abegaz
- Department of Clinical Pharmacy, University of Gondar, College of Medicine and Health Sciences, Gondar, Ethiopia
| | - Asim A Elnour
- Faculty of Pharmacy, Program Lead, Fatima College and Health Sciences (FCHS), Al Ain, United Arab Emirates
| | - Hani M Sabbour
- Department of Cardiology, Brown University Warren Alpert School of Medicine, Rhode Island, United States
| | - Masood Uzzafer
- Health Informatics Consultant, Dallas, Texas, United States
| | - Ahmed Hersi
- Department of Cardiac Sciences, King Saud University, College of Medicine, Riyadh, Saudi Arabia
| | - Adel K Hamad
- Mohammed bin Khalifa Al Khalifa Cardiac Centre, Bahrain Defence Force Hospital, Ar-Rifaa, Bahrain
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11
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Martinez C, Wallenhorst C, Rietbrock S, Freedman B. Ischemic Stroke and Transient Ischemic Attack Risk Following Vitamin K Antagonist Cessation in Newly Diagnosed Atrial Fibrillation: A Cohort Study. J Am Heart Assoc 2020; 9:e014376. [PMID: 31937194 PMCID: PMC7033838 DOI: 10.1161/jaha.119.014376] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background In nonvalvular atrial fibrillation (AF), oral anticoagulants prevent ischemic strokes and transient ischemic attacks (TIAs), but nonpersistence with vitamin K antagonist (VKA) oral anticoagulant therapy (20-50% at 1 year) is problematic. The precise risk of stroke/TIA after VKA cessation and its time course during extended follow-up is unknown. Methods and Results The study cohort of incident AF in patients receiving initial VKA between 2001 and 2013 was identified from the UK Clinical Practice Research Datalink (linked hospitalizations and causes of death). Using a nested case-control analysis, patients with incident stroke/TIA were matched to patients without stroke/TIA (controls). Relative risk with time since VKA cessation compared with current VKA use was approximated from conditional logistic regression. We studied 16 696 patients with incident AF and initial VKA treatment. There were 489 stroke/TIA cases matched to 2137 controls (mean CHA2DS2-VASc score 4.3). Compared with current VKA use, the excess incidence rate of stroke/TIA following VKA cessation in the first year after AF diagnosis was 2.29 (95% CI, 0.98-3.90) per 100 person-years of VKA cessation or 1 additional stroke/TIA per 43 patients per year discontinuing VKA, compared with 1.43 (95% CI, 0.97-1.88) per 100 person-years corresponding to 1 additional stroke/TIA per 70 patients per year, when VKA was discontinued more than 1 year after AF diagnosis. Conclusions VKA cessation is associated with a continuous excess thromboembolic stroke/TIA risk. Increasing oral anticoagulant persistence, especially in the year after AF diagnosis, should be a therapeutic target to reduce stroke/TIA in AF.
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Affiliation(s)
- Carlos Martinez
- Institute for Epidemiology, Statistics and Informatics GmbHFrankfurtGermany
| | | | - Stephan Rietbrock
- Institute for Epidemiology, Statistics and Informatics GmbHFrankfurtGermany
| | - Ben Freedman
- Heart Research InstituteCharles Perkins CentreUniversity of SydneyAustralia
- Department of Cardiology and Anzac Research InstituteConcord HospitalSydneyAustralia
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12
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Cruz-González I, González-Ferreiro R, Freixa X, Gafoor S, Shakir S, Omran H, Berti S, Santoro G, Kefer J, Landmesser U, Nielsen-Kudsk JE, Kanagaratnam P, Nietlispach F, Gloekler S, Aminian A, Danna P, Rezzaghi M, Stock F, Stolcova M, Paiva L, Costa M, Millán X, Ibrahim R, Tichelbäcker T, Schillinger W, Park JW, Sievert H, Meier B, Tzikas A. Cierre de la orejuela izquierda por ictus pese a la anticoagulación oral (ictus resistente): resultados del registro Amplatzer Cardiac Plug. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.02.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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13
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Cruz-González I, González-Ferreiro R, Freixa X, Gafoor S, Shakir S, Omran H, Berti S, Santoro G, Kefer J, Landmesser U, Nielsen-Kudsk JE, Kanagaratnam P, Nietlispach F, Gloekler S, Aminian A, Danna P, Rezzaghi M, Stock F, Stolcova M, Paiva L, Costa M, Millán X, Ibrahim R, Tichelbäcker T, Schillinger W, Park JW, Sievert H, Meier B, Tzikas A. Left atrial appendage occlusion for stroke despite oral anticoagulation (resistant stroke). Results from the Amplatzer Cardiac Plug registry. ACTA ACUST UNITED AC 2019; 73:28-34. [PMID: 31036510 DOI: 10.1016/j.rec.2019.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/18/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION AND OBJECTIVES Despite the efficacy of oral anticoagulant (OAC) therapy, some patients continue to have a high residual risk and develop a stroke on OAC therapy (resistant stroke [RS]), and there is a lack of evidence on the management of these patients. The aim of this study was to analyze the safety and efficacy of left atrial appendage occlusion (LAAO) as secondary prevention in patients with nonvalvular atrial fibrillation who have experienced a stroke/transient ischemic attack despite OAC treatment. METHODS We analyzed data from the Amplatzer Cardiac Plug multicenter registry on 1047 consecutive patients with nonvalvular atrial fibrillation undergoing LAAO. Patientes with previous stroke on OAC therapy as indication for LAAO were identified and compared with patients with other indications. RESULTS A total of 115 patients (11%) with RS were identified. The CHA2DS2-VASc and the HAS-BLED score were significantly higher in the RS group (respectively 5.5±1.5 vs 4.3±1.6; P <.001; 3.9±1.3 vs 3.1±1.2; P <.001). No significant differences were observed in periprocedural major safety events (7.8 vs 4.5%; P=.1). With a mean clinical follow-up of 16.2±12.2 months, the observed annual stroke/transient ischemic attack rate for the RS group was 2.6% (65% risk reduction) and the observed annual major bleeding rate was 0% (100% risk reduction). CONCLUSIONS Patients with RS undergoing LAAO showed similar safety outcomes to patients without RS, with a significant reduction in stroke/transient ischemic attack and major bleeding events during follow-up. Adequately powered controlled trials are needed to further investigate the use of LAAO in RS patients.
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Affiliation(s)
- Ignacio Cruz-González
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), CIBERCV, Salamanca, Spain.
| | - Rocío González-Ferreiro
- Servicio de Cardiología, Hospital Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), CIBERCV, Salamanca, Spain
| | - Xavier Freixa
- Servicio de Cardiologia, Hospital Clínico, Universidad de Barcelona, Barcelona, Spain
| | - Sameer Gafoor
- Department of Cardiology, CardioVascular Center Frankfurt, Frankfurt, Germany
| | - Samera Shakir
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
| | - Heyder Omran
- Department of Cardiology, University Hospital of Bonn, Bonn, Germany
| | - Sergio Berti
- Department of Cardiology, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Gennaro Santoro
- Department of Cardiology, Ospedale Careggi di Firenze, Florence, Italy
| | - Joelle Kefer
- Department of Cardiology, St-Luc University Hospital, Brussels, Belgium
| | - Ulf Landmesser
- Department of Cardiology, University Hospital of Zurich, Zurich, Switzerland
| | | | - Prapa Kanagaratnam
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fabian Nietlispach
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland; Department of Cardiology, University Hospital of Zurich, Zurich, Switzerland
| | - Steffen Gloekler
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Paolo Danna
- Department of Cardiology Ospedale Luigi Sacco, Milan, Italy
| | - Marco Rezzaghi
- Department of Cardiology, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Friederike Stock
- Department of Cardiology, University Hospital of Bonn, Bonn, Germany
| | | | - Luis Paiva
- Department of Cardiology, Coimbra University Hospital Centre, Coimbra, Portugal
| | - Marco Costa
- Department of Cardiology, Coimbra University Hospital Centre, Coimbra, Portugal
| | - Xavier Millán
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Reda Ibrahim
- Department of Cardiology, Montreal Heart Institute, Montreal, Canada
| | - Tobias Tichelbäcker
- Department of Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Heart Center Cologne, Cologne, Germany
| | - Wolfgang Schillinger
- Department of Cardiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Heart Center Cologne, Cologne, Germany
| | - Jai-Wun Park
- Department of Cardiology, Coburg Hospital, Coburg, Germany
| | - Horst Sievert
- Department of Cardiology, CardioVascular Center Frankfurt, Frankfurt, Germany
| | - Bernhard Meier
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
| | - Apostolos Tzikas
- Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece
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14
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Reading SR, Black MH, Singer DE, Go AS, Fang MC, Udaltsova N, Harrison TN, Wei RX, Liu ILA, Reynolds K. Risk factors for medication non-adherence among atrial fibrillation patients. BMC Cardiovasc Disord 2019; 19:38. [PMID: 30744554 PMCID: PMC6371431 DOI: 10.1186/s12872-019-1019-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 02/04/2019] [Indexed: 12/16/2022] Open
Abstract
Background Atrial fibrillation (AF) patients are routinely prescribed medications to prevent and treat complications, including those from common co-occurring comorbidities. However, adherence to such medications may be suboptimal. Therefore, we sought to identify risk factors for general medication non-adherence in a population of patients with atrial fibrillation. Methods Data were collected from a large, ethnically-diverse cohort of Kaiser Permanente Northern and Southern California adult members with incident diagnosed AF between January 1, 2006 and June 30, 2009. Self-reported questionnaires were completed between May 1, 2010 and September 30, 2010, assessing patient socio-demographics, health behaviors, health status, medical history and medication adherence. Medication adherence was assessed using a previously validated 3-item questionnaire. Medication non-adherence was defined as either taking medication(s) as the doctor prescribed 75% of the time or less, or forgetting or choosing to skip one or more medication(s) once per week or more. Electronic health records were used to obtain additional data on medical history. Multivariable logistic regression analyses examined the associations between patient characteristics and self-reported general medication adherence among patients with complete questionnaire data. Results Among 12,159 patients with complete questionnaire data, 6.3% (n = 771) reported medication non-adherence. Minority race/ethnicity versus non-Hispanic white, not married/with partner versus married/with partner, physical inactivity versus physically active, alcohol use versus no alcohol use, any days of self-reported poor physical health, mental health and/or sleep quality in the past 30 days versus 0 days, memory decline versus no memory decline, inadequate versus adequate health literacy, low-dose aspirin use versus no low-dose aspirin use, and diabetes mellitus were associated with higher adjusted odds of non-adherence, whereas, ages 65–84 years versus < 65 years of age, a Charlson Comorbidity Index score ≥ 3 versus 0, and hypertension were associated with lower adjusted odds of non-adherence. Conclusions Several potentially preventable and/or modifiable risk factors related to medication non-adherence and a few non-modifiable risk factors were identified. These risk factors should be considered when assessing medication adherence among patients diagnosed with AF.
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Affiliation(s)
- Stephanie R Reading
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA
| | - Mary Helen Black
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA
| | - Daniel E Singer
- Department of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.,Departments of Epidemiology, Biostatistics and Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Natalia Udaltsova
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA
| | - Rong X Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Ave., 2nd floor, Pasadena, CA, 91101, USA.
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15
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Lowres N, Giskes K, Hespe C, Freedman B. Reducing Stroke Risk in Atrial Fibrillation: Adherence to Guidelines Has Improved, but Patient Persistence with Anticoagulant Therapy Remains Suboptimal. Korean Circ J 2019; 49:883-907. [PMID: 31535493 PMCID: PMC6753021 DOI: 10.4070/kcj.2019.0234] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/24/2022] Open
Abstract
Atrial fibrillation (AF) is a significant risk factor for avoidable stroke. Among high-risk patients with AF, stroke risk can be mitigated using oral anticoagulants (OACs), however reduction is largely contingent on physician prescription and patient persistence with OAC therapy. Over the past decade significant advances have occurred, with revisions to clinical practice guidelines relating to management of stroke risk in AF in several countries, and the introduction of non-vitamin K antagonist OACs (NOACs). This paper summarises the evolving body of research examining guideline-based clinician prescription over the past decade, and patient-level factors associated with OAC persistence. The review shows clinicians' management over the past decade has increasingly reflected guideline recommendations, with an increasing proportion of high-risk patients receiving OACs, driven by an upswing in NOACs. However, a treatment gap remains, as 25–35% of high-risk patients still do not receive OAC treatment, with great variation between countries. Reduction in stroke risk directly relates to level of OAC prescription and therapy persistence. Persistence and adherence to OAC thromboprophylaxis remains an ongoing issue, with 2-year persistence as low as 50%, again with wide variation between countries and practice settings. Multiple patient-level factors contribute to poor persistence, in addition to concerns about bleeding. Considered review of individual patient's factors and circumstances will assist clinicians to implement appropriate strategies to address poor persistence. This review highlights the interplay of both clinician's awareness of guideline recommendations and understanding of individual patient-level factors which impact adherence and persistence, which are required to reduce the incidence of preventable stroke attributable to AF.
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Affiliation(s)
- Nicole Lowres
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Katrina Giskes
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Charlotte Hespe
- School of Medicine, The University of Notre Dame, Sydney, Australia
| | - Ben Freedman
- Heart Research Institute, Charles Perkins Centre, Camperdown, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Cardiology, Concord Hospital, The University of Sydney Concord Clinical School, Concord, Australia
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16
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Hurtado-Navarro I, García-Sempere A, Rodríguez-Bernal C, Santa-Ana-Tellez Y, Peiró S, Sanfélix-Gimeno G. Estimating Adherence Based on Prescription or Dispensation Information: Impact on Thresholds and Outcomes. A Real-World Study With Atrial Fibrillation Patients Treated With Oral Anticoagulants in Spain. Front Pharmacol 2018; 9:1353. [PMID: 30559661 PMCID: PMC6287024 DOI: 10.3389/fphar.2018.01353] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 11/05/2018] [Indexed: 01/13/2023] Open
Abstract
Objective: To estimate drug exposure, Proportion of Days Covered (PDC) and percentage of patients with PDC ≥ 80% from a cohort of atrial fibrillation patients initiating oral anticoagulant (OAC) treatment. We employed three different approaches to estimate PDC, using either data from prescription and dispensing (PD cohort) or two common designs based on dispensing information only, requiring at least one (D1) or at least two (D2) refills for inclusion in the cohorts. Finally, we assessed the impact of adherence on health outcomes according to each method. Methods: Population-based retrospective cohort of all patients with Non Valvular Atrial Fibrillation (NVAF), who were newly prescribed acenocoumarol, apixaban, dabigatran or rivaroxaban from November 2011 to December 2015 in the region of Valencia (Spain). Patients were followed for 12 months to assess adherence using three different approaches (PD, D1 and D2 cohorts). To analyze the relationship between adherence (PDC ≥ 80) defined according to each method of calculation and health outcomes (death for any cause, stroke or bleeding) Cox regression models were used. For the identification of clinical events patients were followed from the end of the adherence assessment period to the end of the available follow-up period. Results: PD cohort included all patients with an OAC prescription (n = 38,802), D1 cohort excluded fully non-adherent patients (n = 265) and D2 cohort also excluded patients without two refills separated by 180 days (n = 2,614). PDC ≥ 80% ranged from 94% in the PD cohort to 75% in the D1 cohort. Drug exposure among adherent (PDC ≥ 80%) and non-adherent (PDC < 80%) patients was different between cohorts. In adjusted analysis, high adherence was associated with a reduced risk of death [Hazard Ratio (HR): from 0.82 to 0.86] and (except in the PD cohort) the risk for ischemic stroke (HR: from 0.61 to 0.64) without increasing the risk of bleeding. Conclusion: Common approaches to assess adherence using measures based on days' supply exclude groups of non-adherent patients and, also, misattribute periods of doctors' discontinuation to patient non-adherence, misestimating adherence overall. Physician-initiated discontinuation is a major contributor to reduced OAC exposure. When using the PDC80 threshold, very different groups of patients may be classified as adherent or non-adherent depending on the method used for the calculation of days' supply measures. High adherence and high exposure to OAC treatment in NVAF patients is associated with better health outcomes.
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Affiliation(s)
- Isabel Hurtado-Navarro
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
| | - Aníbal García-Sempere
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
| | - Clara Rodríguez-Bernal
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
| | - Yared Santa-Ana-Tellez
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
| | - Salvador Peiró
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana, Valencia, Spain.,Red de Investigación en Servicios de Salud en Enfermedades Crónicas, Valencia, Spain
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17
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Lip GYH, Pan X, Kamble S, Kawabata H, Mardekian J, Masseria C, Phatak H. Discontinuation risk comparison among 'real-world' newly anticoagulated atrial fibrillation patients: Apixaban, warfarin, dabigatran, or rivaroxaban. PLoS One 2018; 13:e0195950. [PMID: 29709012 PMCID: PMC5927458 DOI: 10.1371/journal.pone.0195950] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 04/03/2018] [Indexed: 02/06/2023] Open
Abstract
Discontinuation of oral anticoagulants may expose non-valvular atrial fibrillation (NVAF) patients to an increased risk of stroke. This study describes the real-world discontinuation rates and compared the risk of drug discontinuation among NVAF patients initiating apixaban, warfarin, dabigatran, or rivaroxaban. This retrospective cohort study evaluated newly-anticoagulated NVAF patients in the MarketScan® data population from 01/01/2012 through 12/31/2014. Discontinuation was defined as a lack of subsequent prescription of the index drug within 30 days after the last supply day of the last prescription. A Cox model was used to estimate the hazard ratio (HR) of discontinuation, adjusted for age, sex, and comorbidities. Among 45,361 eligible NVAF patients, 15,461 (34.1%) initiated warfarin; 7,438 (16.4%) apixaban; 4,661 (10.3%) dabigatran; and 17,801 (39.2%) initiated rivaroxaban treatment. Compared to warfarin, patients who initiated dabigatran (adjusted HR [aHR]: 0.84, 95% confidence interval [CI]: 0.80–0.87, P<0.001), rivaroxaban (aHR: 0.70, 95% CI: 0.68–0.73, P<0.001), or apixaban (aHR: 0.57, 95% CI: 0.55–0.60, P<0.001) were 16%, 30%, and 43% less likely to discontinue treatment, respectively. When compared to apixaban, patients who initiated dabigatran (aHR: 1.46, 95% CI: 1.38–1.54, P<0.001) or rivaroxaban (aHR: 1.23, 95% CI: 1.17–1.28, P<0.001) were more likely to discontinue treatment. Among newly-anticoagulated NVAF patients in the real-world setting, initiation on rivaroxaban, dabigatran, or apixaban was associated with a significantly lower risk of discontinuation compared to warfarin. When compared to apixaban, patients who initiated treatment with warfarin, dabigatran, or rivaroxaban were more likely to discontinue treatment.
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Affiliation(s)
- Gregory Y. H. Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- * E-mail:
| | - Xianying Pan
- Center for Observational Research and Data Science, Bristol-Myers Squibb Company (BMS), Princeton, New Jersey, United States of America
| | - Shital Kamble
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb Company (BMS), Princeton, New Jersey, United States of America
| | - Hugh Kawabata
- Center for Observational Research and Data Science, Bristol-Myers Squibb Company (BMS), Princeton, New Jersey, United States of America
| | - Jack Mardekian
- Outcomes & Evidence, Patient & Health Impact, Pfizer Inc., New York, New York, United States of America
| | - Cristina Masseria
- Outcomes & Evidence, Patient & Health Impact, Pfizer Inc., New York, New York, United States of America
| | - Hemant Phatak
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb Company (BMS), Princeton, New Jersey, United States of America
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18
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Henk HJ, Cao F, Tuell K, Price K, Singh P, Mardekian J, Odell K, Patel C, Tan W, Sands GH, Singhal S, Trocio J, Vo L. Treatment and discharge patterns among patients hospitalized with non-valvular atrial fibrillation transitioning from the inpatient to outpatient setting. Curr Med Res Opin 2018; 34:539-546. [PMID: 29235900 DOI: 10.1080/03007995.2017.1417029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate inpatient oral anticoagulant (OAC) treatment, discharge location, and post-discharge OAC treatment for patients hospitalized with non-valvular atrial fibrillation (NVAF). RESEARCH DESIGN AND METHODS Retrospective study using claims data linked to hospital electronic health records (EHR). Patients (n = 2,484) were hospitalized with a primary (38%) or secondary (62%) diagnosis of AF without evidence of mitral valvular heart disease or valve replacement between January 2009 and September 2013. Inpatient OAC treatment was identified from EHR data. MAIN OUTCOME MEASURES Inpatient and post-discharge OAC treatment [direct OAC (DOAC; apixaban, rivaroxaban, dabigatran), warfarin, no OAC] and discharge location (long-term care, home health-care, home self-care). RESULTS Mean age was 72.6 years, 61.2% were male, and 89.5% had a CHA2DS2-VASc score ≥2. Overall, 6.4% received a DOAC, 38.0% warfarin, and 55.6% no OAC during hospitalization. Compared to other treatment groups, patients receiving DOAC were younger and more likely to be male. The majority (72.2%) were discharged to home health-care, 13.2% home self-care, and 6.0% long-term care. Among patients who were treated with warfarin during hospitalization, 40.3% filled a warfarin prescription within 30 days post-discharge, whereas among patients who were treated with a DOAC, 52.4% filled a DOAC prescription within 30 days post-discharge. Some NVAF patients not treated with an OAC during hospitalization filled a prescription for warfarin (18.0%) or DOAC (1.9%) within 30 days post-discharge. Results were similar among patients with CHA2DS2-VASc score ≥2. CONCLUSIONS Most patients hospitalized for NVAF were discharged to home support, and the majority did not have OAC treatment during hospitalization or the 30 days post-discharge. Additional investigation should be conducted on trends beyond 30 days post-hospitalization, and the reasons for not receiving anticoagulation therapy in patients at moderate-to-severe risk of stroke or systemic embolism. Helping to avoid preventable strokes is an important goal for public health.
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Affiliation(s)
- Henry J Henk
- a Health Economics and Outcomes Research, Optum , Eden Prairie , MN , USA
| | - Feng Cao
- a Health Economics and Outcomes Research, Optum , Eden Prairie , MN , USA
| | - Kenneth Tuell
- b Health Economics and Outcomes Research, Bristol Myers-Squibb , Princeton , NJ , USA
| | - Kwanza Price
- c Health Economics and Outcomes Research, Pfizer , New York , NY , USA
| | - Prianka Singh
- b Health Economics and Outcomes Research, Bristol Myers-Squibb , Princeton , NJ , USA
| | - Jack Mardekian
- c Health Economics and Outcomes Research, Pfizer , New York , NY , USA
| | - Kevin Odell
- c Health Economics and Outcomes Research, Pfizer , New York , NY , USA
| | - Chad Patel
- b Health Economics and Outcomes Research, Bristol Myers-Squibb , Princeton , NJ , USA
| | - Wilson Tan
- d US Medical Affairs, Pfizer , New York , NY , USA
| | | | - Shalabh Singhal
- b Health Economics and Outcomes Research, Bristol Myers-Squibb , Princeton , NJ , USA
| | - Jeffrey Trocio
- c Health Economics and Outcomes Research, Pfizer , New York , NY , USA
| | - Lien Vo
- b Health Economics and Outcomes Research, Bristol Myers-Squibb , Princeton , NJ , USA
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Stephenson JJ, Shinde MU, Kwong WJ, Fu AC, Tan H, Weintraub WS. Comparison of claims vs patient-reported adherence measures and associated outcomes among patients with nonvalvular atrial fibrillation using oral anticoagulant therapy. Patient Prefer Adherence 2018; 12:105-117. [PMID: 29391782 PMCID: PMC5769561 DOI: 10.2147/ppa.s148697] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To compare oral anticoagulant (OAC) adherence among patients with nonvalvular atrial fibrillation (NVAF) using patient-reported and claims-based measures, and to evaluate the effect of OAC adherence on health care costs and patient satisfaction with OAC therapy. METHODS This was a hybrid US observational study consisting of a longitudinal cohort survey followed by linkage and analysis of respondents' administrative claims data. Patients with NVAF receiving warfarin, dabigatran, rivaroxaban, or apixaban completed an initial survey and follow-up surveys at 4, 8, and 12 months. Patient-reported adherence was measured at each survey by Morisky Medication Adherence Scale (MMAS-8) and pharmacy claims-determined adherence by the proportion of days covered (PDC) for the 12-month period following the initial survey date; adherence was defined as MMAS-8 score =8 and PDC ≥80%. Patient satisfaction with OAC therapy was assessed by the Duke Anticoagulation Satisfaction Scale (DASS). RESULTS Overall, 675 patients completed at least the initial survey (warfarin, n=271; dabigatran, n=266; rivaroxaban, n=128; apixaban, n=10). Fewer than half (47.9%) were PDC adherent, 37.2% were MMAS-8 adherent, and 19.4% were adherent by both measures. Total medical costs of PDC-adherent patients were significantly lower vs PDC-nonadherent patients (US$640 vs $993 per-patient per-month, respectively, p<0.05). MMAS-8-adherent patients reported higher treatment satisfaction; total DASS score was significantly lower among MMAS-8-adherent than MMAS-8-nonadherent patients (37.3 vs 42.9, respectively, p<0.001). CONCLUSION Using claims-based or patient-reported methods to measure OAC adherence may lead to different results when assessing impact on health care costs and satisfaction with anticoagulation medication. These results underscore the importance of considering both claims-based and patient-reported measures when evaluating treatment adherence in real-world settings.
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Affiliation(s)
- Judith J Stephenson
- HealthCore, Inc., Wilmington, DE
- Correspondence: Judith J Stephenson, HealthCore, Inc., 123 Justison Street, Suite 200, Wilmington, DE 19801, USA, Tel +1 302 230 2142, Fax +1 302 230 2020, Email
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Wilke T, Groth A, Fuchs A, Pfannkuche M, Maywald U. Persistence with VKA treatment in newly treated atrial fibrillation patients: an analysis based on a large sample of 38,076 German patients. Eur J Clin Pharmacol 2017; 73:1437-1447. [PMID: 28780697 DOI: 10.1007/s00228-017-2307-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 07/17/2017] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this study was to describe persistence with vitamin K antagonist (VKA) treatment in German atrial fibrillation (AF) patients and to identify factors which may be associated with early discontinuation of VKA therapy. METHODS We did a retrospective cohort study based on an anonymized German claims dataset with VKA treatment-naïve AF patients, who received at least one VKA prescription. VKA therapy discontinuation was defined as a gap >180 days. RESULTS We identified 38,076 VKA patients who started a VKA therapy (mean age 76.13 years; 56.08% female; mean CHA2DS2-VASc-Score 4.49; mean Charlson Comorbidity Index (CCI) 3.91). After four quarters since start of VKA treatment, 14,889 (39.10%) of observed patients had discontinued their VKA treatment (after eight quarters: 54.61%). Mean time until treatment discontinuation was 390.55 days. Risk of VKA discontinuation increased with the diagnosis of dementia within the first two quarters of VKA treatment [HR 1.35 (95% CI 1.29-1.40)], diagnosed alcohol or drug abuse in the baseline period [HR 1.25; 95% CI 1.18-1.33)], female gender [HR 1.08; 95% CI 1.05-1.10)], higher age (HR 1.03; 95% CI 1.03-1.03), higher CCI (HR 1.05; 95% CI 1.04-1.05), any prescription of NSAID (HR 1.07; 95% CI 1.04-1.10), and number of surgeries in the first two quarters of VKA treatment (HR 1.05; 95% CI 1.04-1.05). At least one yearly visit to a cardiologist since start of VKA treatment decreased the risk of non-persistence [HR 0.90; 95% CI 0.88-0.93] and a cancer diagnosis in the baseline period (HR 0.92; 95% CI 0.89-0.96). CONCLUSION Non-persistence related to VKA therapy is common in AF patients. Older more comorbid female patients as well as patients who face surgeries and who do not visit a cardiologist regularly face a higher therapy discontinuation risk.
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Affiliation(s)
- Thomas Wilke
- Institut für Pharmakoökonomie und Arzneimittellogistik (IPAM), Hochschule Wismar, Germany.
| | - Antje Groth
- Institut für Pharmakoökonomie und Arzneimittellogistik (IPAM), Hochschule Wismar, Germany
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Nelson WW, Laliberté F, Patel AA, Germain G, Pilon D, McCormick N, Lefebvre P. Stroke risk reduction outweighed bleeding risk increase from vitamin K antagonist treatment among nonvalvular atrial fibrillation patients with high stroke risk and low bleeding risk. Curr Med Res Opin 2017; 33:631-638. [PMID: 28008771 DOI: 10.1080/03007995.2016.1275936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Warfarin is widely used for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). We compared the rates of stroke and major bleeding in NVAF patients with a high stroke risk and low bleeding risk profile during warfarin treated (W+) and warfarin untreated (W-) periods. METHOD Insurance claims from six commercial, Medicaid or Medicare databases were analyzed from 2000 to 2014. NVAF patients treated with warfarin, with a CHADS2/CHA2DS2-VASc score ≥2, and an ATRIA score ≤3 at baseline were identified. Incidence rate ratios (IRRs) of stroke and major bleeding were calculated for W + versus W- episodes of person-time, as well as for first 30 days versus beyond 30 days of W + episodes. RESULTS Among 316,145 patients, anticoagulant prophylaxis with warfarin significantly reduced stroke risk, with IRRs ranging from 0.48 (95% CI: 0.46-0.51) to 0.80 (95% CI: 0.70-0.91), and increased major bleeding risk, with IRRs ranging from 1.13 (95% CI: 1.10-1.15) to 1.95 (95% CI: 1.10-3.45). Stroke and major bleeding rates were higher during the first 30 days of W + than beyond. CONCLUSION In NVAF patients at high risk for stroke and low risk for bleeding, our data confirm the effectiveness of anticoagulation for stroke prevention. The decrease in stroke risk of anticoagulation may outweigh the risk of major bleeding events, particularly among elderly patients. Potential risks of warfarin during initiation warrant attention, especially among patients who stop and start therapy repeatedly.
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Affiliation(s)
| | | | - Aarti A Patel
- a Janssen Scientific Affairs LLC , Raritan , NJ , USA
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Deitelzweig SB, Evans M, Trocio J, Gupta K, Lingohr-Smith M, Menges B, Lin J. Impact of Warfarin Persistence on Health-Care Utilization and Costs Among Patients With Atrial Fibrillation Managed in Anticoagulation Clinics in the United States. Clin Appl Thromb Hemost 2017; 24:364-371. [PMID: 28135822 DOI: 10.1177/1076029616685427] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Warfarin is a recommended therapy to reduce the risk of stroke in patients with nonvalvular atrial fibrillation (NVAF). The objectives of this study were to identify potential factors associated with warfarin persistence and evaluate the impact of warfarin persistence on health-care resource utilization and costs among patients with NVAF in the United States. Patients (≥18 years) with ≥1 inpatient or ≥2 outpatient diagnoses of AF without valvular disease were identified from an electronic medical record database (January 1, 2004, to January 31, 2015). The patients with NVAF were grouped into 2 cohorts-persistent with warfarin therapy and not persistent (warfarin discontinuation in <365 days). A multivariable regression was used to identify potential predictors of warfarin persistence. Health-care costs were evaluated during a 12-month follow-up period for study cohorts. Among the study population, 52%, (n = 4086) were persistent with warfarin therapy and 48% (n = 3722) were not. Patients with NVAF with higher Charlson comorbidity index and CHADS2 scores versus those with scores of 0 were more likely to demonstrate persistence with warfarin therapy. After adjusting for patient characteristics, patients with NVAF persistent with warfarin therapy versus those who were not were 30% less likely to be hospitalized during the follow-up period ( P < .001). Additionally, total all-cause health-care costs (US $2183, P < .001) and stroke-related costs (US $788, P < .001) were significantly lower among patients persistent with warfarin therapy versus those who were not. Patients with NVAF who have greater comorbidity and stroke risk are more likely to be persistent with warfarin therapy. Patients with NVAF who are persistent with warfarin therapy versus those who are not have lower all-cause and stroke-related health-care costs.
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Affiliation(s)
- Steven B Deitelzweig
- 1 Department of Hospital Medicine, Ochsner Clinic Foundation, Ochsner Health System, New Orleans, LA, USA
| | - Michael Evans
- 2 Geisinger Health System, Enterprise Pharmacy, Danville, PA, USA
| | - Jeffrey Trocio
- 3 Global Health and Value, Outcomes and Evidence, Pfizer, Inc, New York, NY, USA
| | - Kiran Gupta
- 4 Health Economics and Outcomes Research, Bristol-Myers Squibb, Plainsboro, NJ, USA
| | | | - Brandy Menges
- 5 Health Economics and Outcomes Research, Novosys Health, Green Brook, NJ, USA
| | - Jay Lin
- 5 Health Economics and Outcomes Research, Novosys Health, Green Brook, NJ, USA
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Suzuki T, Shiga T, Omori H, Tatsumi F, Nishimura K, Hagiwara N. Adherence to medication and characteristics of Japanese patients with non-valvular atrial fibrillation. J Cardiol 2016; 70:238-243. [PMID: 28007412 DOI: 10.1016/j.jjcc.2016.11.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/07/2016] [Accepted: 11/21/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND Adherence to medication plays an important role in the prevention of morbidity and mortality in non-valvular atrial fibrillation (NVAF) patients. The aim of this study is to assess adherence to medication and risk factors for non-adherence in Japanese NVAF patients who are prescribed anticoagulants. METHODS A total of 378 outpatients with NVAF who completed self-reported questionnaires were analyzed in this prospective study (mean age 69±12 years; 26% female). Self-reported adherence to cardiovascular drugs including anticoagulants was measured with a modified Siegal scale. Depression was defined as a Patient Health Questionnaire-9 score of ≥10. Univariate and multivariate analyses were performed on several variables to analyze factors affecting non-adherence. RESULTS In total, 291 (77%) of our patients received warfarin, and the remainder received direct oral anticoagulants. Fifty-two (14%) patients were defined as non-adherent. Univariate analyses showed that age <65 years, ≥2 times daily dosing of cardiovascular drugs and employment, but not depression, were significantly associated with non-adherence, 1.87 (95% CI: 1.01-3.42, p=0.04), 2.97 (95% CI: 1.64-5.49, p<0.01), 2.11 (95% CI: 1.16-3.93, p=0.01), and 0.74 (95% CI: 0.26-2.64), respectively. Multivariate analysis showed that only ≥2 times daily dosing was a significant independent risk factor (HR 3.06, 95% CI: 1.67-5.69, p<0.01). CONCLUSIONS Our study showed that the prevalence of non-adherence to medications was 14% in NVAF patients. Frequent daily dosing was an independent risk factor for non-adherence to medication (UMIN-CTR No. UMIN 000023514).
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Affiliation(s)
- Tsuyoshi Suzuki
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan.
| | - Hisako Omori
- Department of Medicine, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Fujio Tatsumi
- Department of Cardiology, Tokyo Women's Medical University Aoyama Hospital, Tokyo, Japan
| | - Katsuji Nishimura
- Department of Psychiatry, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
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Cano L, Cardona P, Quesada H, Lara B, Rubio F. Ischaemic stroke in patients treated with oral anticoagulants. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2014.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Alamneh EA, Chalmers L, Bereznicki LR. Suboptimal Use of Oral Anticoagulants in Atrial Fibrillation: Has the Introduction of Direct Oral Anticoagulants Improved Prescribing Practices? Am J Cardiovasc Drugs 2016; 16:183-200. [PMID: 26862063 DOI: 10.1007/s40256-016-0161-8] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Atrial fibrillation (AF) and the associated risk of stroke are emerging epidemics throughout the world. Suboptimal use of oral anticoagulants for stroke prevention has been widely reported from observational studies. In recent years, direct oral anticoagulants (DOACs) have been introduced for thromboprophylaxis. We conducted a systematic literature review to evaluate current practices of anticoagulation in AF, pharmacologic features and adoption patterns of DOACs, their impacts on proportion of eligible patients with AF who receive oral anticoagulants, persisting challenges and future prospects for optimal anticoagulation. LITERATURE SOURCE AND SELECTION CRITERIA In conducting this review, we considered the results of relevant prospective and retrospective observational studies from real-world practice settings. PubMed (MEDLINE), Scopus (RIS), Google Scholar, EMBASE and Web of Science were used to source relevant literature. There were no date limitations, while language was limited to English. Selection was limited to articles from peer reviewed journals and related to our topic. RESULTS Most studies identified in this review indicated suboptimal use of anticoagulants is a persisting challenge despite the availability of DOACs. Underuse of oral anticoagulants is apparent particularly in patients with a high risk of stroke. DOAC adoption trends are quite variable, with slow integration into clinical practice reported in most countries; there has been limited impact to date on prescribing practice. CONCLUSION Available data from clinical practice suggest that suboptimal oral anticoagulant use in patients with AF and poor compliance with guidelines still remain commonplace despite transition to a new era of anticoagulation featuring DOACs.
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Affiliation(s)
- Endalkachew A Alamneh
- Division of Pharmacy, School of Medicine, University of Tasmania, Tasmania, Australia.
| | - Leanne Chalmers
- Division of Pharmacy, School of Medicine, University of Tasmania, Tasmania, Australia
| | - Luke R Bereznicki
- Division of Pharmacy, School of Medicine, University of Tasmania, Tasmania, Australia
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Abdou JK, Auyeung V, Patel JP, Arya R. Adherence to long-term anticoagulation treatment, what is known and what the future might hold. Br J Haematol 2016; 174:30-42. [DOI: 10.1111/bjh.14134] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- John K. Abdou
- Institute of Pharmaceutical Science; King's College London; London UK
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital Foundation NHS Trust, Denmark Hill; London UK
| | - Vivian Auyeung
- Institute of Pharmaceutical Science; King's College London; London UK
| | - Jignesh P. Patel
- Institute of Pharmaceutical Science; King's College London; London UK
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital Foundation NHS Trust, Denmark Hill; London UK
| | - Roopen Arya
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital Foundation NHS Trust, Denmark Hill; London UK
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Spivey CA, Liu X, Qiao Y, Mardekian J, Parker RB, Phatak H, Masseria C, Kachroo S, Abdulsattar Y, Wang J. Stroke associated with discontinuation of warfarin therapy for atrial fibrillation. Curr Med Res Opin 2015; 31:2021-9. [PMID: 26390258 DOI: 10.1185/03007995.2015.1082995] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The objective of this study was to determine the association between warfarin discontinuation and stroke among patients with nonvalvular atrial fibrillation (NVAF). RESEARCH DESIGN AND METHODS This was a retrospective, observational study of adult NVAF patients (≥ 18 years) who were on warfarin in the Truven MarketScan commercial claims and encounters and Medicare supplemental and coordination of benefits databases (1 January 2008 to 30 June 2012). Warfarin discontinuation was defined as a gap of ≥ 45 days in warfarin prescription within 1 year after initiation. Patients who did and did not discontinue warfarin were matched at a 1:1 ratio using a propensity score method. Matched patients were followed for up to 1 year to determine risks of ischemic stroke, transient ischemic attack (TIA), and hemorrhagic stroke. A multivariate Cox proportional hazards model was used to further adjust for the effects of potential confounders. RESULTS A total of 27,000 patients were included. Patients who discontinued warfarin had higher rates of ischemic stroke compared to persistent patients (1.0 vs. 0.5 per 100 patient years, P < 0.01), but similar rates of TIA (1.2 vs. 0.9 per 100 patient years, respectively; P = 0.07) and hemorrhagic stroke (0.3 vs. 0.2 per 100 patient years, P = 0.31). After adjustment for potential confounders, warfarin discontinuation was significantly associated with increased risk of ischemic stroke (hazard ratio [HR]: 2.04; 95% confidence interval [CI]: 1.47-2.84), TIA (HR: 1.36; 95% CI: 1.04-1.78), and ischemic stroke or TIA (HR: 1.50; 95% CI: 1.20-1.87). CONCLUSIONS Warfarin discontinuation is associated with increased risk of ischemic stroke and TIA. Health care providers may need to take a more active role in the management of warfarin discontinuation and clinical outcomes, e.g., by considering newer anticoagulants with favorable risk-benefit profiles. Key limitations of the study include unavailability of important clinical factors and measures in claims data.
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Affiliation(s)
| | - Xianchen Liu
- a a University of Tennessee College of Pharmacy , Memphis , TN , USA
- b b Global Health Economics & Outcomes Research, Pfizer Inc. , New York , NY , USA
| | - Yanru Qiao
- a a University of Tennessee College of Pharmacy , Memphis , TN , USA
| | | | - Robert B Parker
- a a University of Tennessee College of Pharmacy , Memphis , TN , USA
| | - Hemant Phatak
- d d Global Health Economics & Outcomes Research , Bristol-Myers Squibb, Princeton , NJ , USA
| | - Cristina Masseria
- e e Global Health Economics & Outcomes Research, Pfizer Inc. , New York , NY , USA
| | - Sumesh Kachroo
- d d Global Health Economics & Outcomes Research , Bristol-Myers Squibb, Princeton , NJ , USA
| | | | - Junling Wang
- a a University of Tennessee College of Pharmacy , Memphis , TN , USA
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Sanfélix-Gimeno G, Rodríguez-Bernal CL, Hurtado I, Baixáuli-Pérez C, Librero J, Peiró S. Adherence to oral anticoagulants in patients with atrial fibrillation-a population-based retrospective cohort study linking health information systems in the Valencia region, Spain: a study protocol. BMJ Open 2015; 5:e007613. [PMID: 26482766 PMCID: PMC4611755 DOI: 10.1136/bmjopen-2015-007613] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Adherence to oral anticoagulation (OAC) treatment, vitamin K antagonists or new oral anticoagulants, is an essential element for effectiveness. Information on adherence to OAC in atrial fibrillation (AF) and the impact of adherence on clinical outcomes using real-world data barely exists. We aim to describe the patterns of adherence to OAC over time in patients with AF, estimate the associated factors and their impact on clinical events, and assess the same issues with conventional measures of primary and secondary adherence-proportion of days covered (PDC) and persistence-in routine clinical practice. METHODS AND ANALYSIS This is a population-based retrospective cohort study including all patients with AF treated with OAC from 2010 to date in Valencia, Spain; data will be obtained from diverse electronic records of the Valencia Health Agency. PRIMARY OUTCOME MEASURE adherence trajectories. SECONDARY OUTCOMES (1) primary non-adherence; (2) secondary adherence: (a) PDC, (b) persistence. Clinical outcomes: hospitalisation for haemorrhagic or thromboembolic events and death during follow-up. ANALYSIS (1) description of baseline characteristics, adherence patterns (trajectory models or latent class growth analysis models) and conventional adherence measures; (2) logistic or Cox multivariate regression models, to assess the associations between adherence measures and the covariates, and logistic multinomial regression models, to identify characteristics associated with each trajectory; (3) Cox proportional hazard models, to assess the relationship between adherence and clinical outcomes, with propensity score adjustment applied to further control for potential confounders; (4) to estimate the importance of different healthcare levels in the variations of adherence, logistic or Cox multilevel regression models. ETHICS AND DISSEMINATION This study has been approved by the corresponding Clinical Research Ethics Committee. We plan to disseminate the project's findings through peer-reviewed publications and presentations at relevant health conferences. Policy reports will also be prepared in order to promote the translation of our findings into policy and clinical practice.
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Affiliation(s)
- G Sanfélix-Gimeno
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - C L Rodríguez-Bernal
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - I Hurtado
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - C Baixáuli-Pérez
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - J Librero
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - S Peiró
- Health Services Research Unit, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunidad Valenciana (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
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Spivey CA, Qiao Y, Liu X, Mardekian J, Parker RB, Phatak H, Claflin AB, Kachroo S, Abdulsattar Y, Chakrabarti A, Wang J. Discontinuation/Interruption of Warfarin Therapy in Patients with Nonvalvular Atrial Fibrillation. J Manag Care Spec Pharm 2015; 21:596-606. [PMID: 26108384 PMCID: PMC10398305 DOI: 10.18553/jmcp.2015.21.7.596] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Use of warfarin is standard of care for stroke prevention in patients with atrial fibrillation (AF). However, AF patients experience high rates of warfarin discontinuation/interruption, resulting in increased health risks and health care costs. As such, it is important to study the rates and predictors of warfarin discontinuation/interruption in this population. OBJECTIVES To determine (a) rates of warfarin discontinuation and interruption and (b) demographic, clinical, and health care-related factors associated with discontinuation and interruption in patients with nonvalvular AF (NVAF) in the usual clinical practice settings in the United States. METHODS This retrospective cohort study used the MarketScan Database and included patients (aged ≥ 18 years) with NVAF who were initiated on warfarin. The study period was January 1, 2008, to June 30, 2012. To be included, patients were required to have at least 2 claims with AF diagnosis separated by ≥ 30 days and ≤ 12 months and at least 1 outpatient claim. Warfarin initiation had to occur within 30 days of the AF diagnosis. Patients also had to have continuous enrollment in prescription drug plans from 6 months prior to warfarin use to at least 12 months after warfarin initiation. Patients were followed for 1 year after warfarin initiation. Persistence was defined as warfarin therapy without a gap ≥ 45 days between the end date of the former prescription and the start date of the current prescription or with international normalized ratio (INR) monitoring at least every 42 days. Interruption was defined as a gap in warfarin therapy ≥ 45 days and ≤ 90 days between the end date of the former prescription and the start date of the current prescription and without INR monitoring at least every 42 days. Discontinuation was defined as greater than 90 days without warfarin therapy between the end date of the former prescription and the start date of the current prescription and without INR monitoring at least every 42 days. Chi-square tests were used to analyze categorical variables, and independent samples t-tests were used for continuous variables. Cox proportional hazards regression model was performed to determine factors associated with warfarin discontinuation/interruption, including demographic (e.g., age, gender); clinical (e.g., comorbidities, CHADS2 score); and health care-related (e.g., hospitalizations or emergency room visits) characteristics. Sensitivity analyses were conducted by varying prescription gaps by 7, 14, and 30 days. RESULTS A total of 58,593 patients with NVAF were included. The mean age was approximately 71 years (SD = 12.00) and mean CHADS2 score was 1.66 (SD = 1.23). The majority of patients were male (60%). During 12 months after warfarin initiation, 45% of patients were persistent with warfarin; 12% had interruption without discontinuation; and 43% had discontinuation. The risk of warfarin interruption or discontinuation was significantly greater in patients who were younger than 65 years (HR = 1.22; 95% CI = 1.19-1.25), lived in the West (HR = 1.07; 95% CI = 1.03-1.11), had history of anemia (HR = 1.10; 95% CI = 1.06-1.14), had history of bleeding (HR = 1.10; 95% CI = 1.06-1.14), or had history of hospitalization or emergency room visits (HR = 1.11; 95% CI = 1.08-1.13). The significant factors associated with interruption and discontinuation were similar. In the sensitivity analyses, the significant factors associated with discontinuation/interruption were similar across different prescription gaps. CONCLUSIONS In the U.S. clinical practice setting, more than 50% of NVAF patients discontinued or interrupted warfarin within 1 year after initiation. Aged less than 65 years, history of anemia, and history of hospitalization/emergency room visits were associated with increased risk of discontinuation/interruption. Given the high prevalence of warfarin discontinuation/interruption, health care providers should take a more active role in understanding and addressing the reasons behind patient discontinuation/interruption.
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Affiliation(s)
- Christina A Spivey
- University of Tennessee College of Pharmacy, 881 Madison Ave., Ste. 221, Memphis, TN 38163.
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López Mínguez JR, Nogales Asensio JM, Gragera JE, Costa M, Cruz González I, Gimeno de Carlos F, Fernández Díaz JA, Martín Yuste V, Moreno González R, Domínguez-Franco A, Benedicto Buendía A, Herrero Garibi J, Hernández Hernández F, Gama Ribeiro V. Two-year clinical outcome from the Iberian registry patients after left atrial appendage closure. Heart 2015; 101:877-83. [DOI: 10.1136/heartjnl-2014-306332] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 12/15/2014] [Indexed: 12/23/2022] Open
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Cano LM, Cardona P, Quesada H, Lara B, Rubio F. Ischaemic stroke in patients treated with oral anticoagulants. Neurologia 2014; 31:395-400. [PMID: 25529172 DOI: 10.1016/j.nrl.2014.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 09/19/2014] [Accepted: 09/25/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Cardioembolic stroke is associated with poorer outcomes. Prevention is based on oral anticoagulant (OAC) therapy. Haemorrhage is the main complication of OACs, which are sometimes ineffective. PATIENTS AND METHODS We retrospectively reviewed 1014 consecutive patients who suffered an ischaemic stroke between 2011 and 2013, analysing those who were receiving OAC treatment at stroke onset (107 patients in total) with special attention to aetiology, outcomes, and INR value in the acute phase. RESULTS The mean age (SD) was 71.9 (10) years. Patients had been treated with OACs for 5.9 (5.5) years; 98.1% of them were being treated for heart disease. INR was <2 in 77 patients (72%), and 30 patients (28%) had an INR≥2. Nine patients (8.4%) had INR values within the therapeutic range. According to TOAST classification criteria, 88.8% of strokes were cardioembolic and 1.9% were atherothrombotic. Anticoagulation therapy was discontinued in 48 patients (44.9%) due to haemorrhagic transformation (24 patients), extensive infarction (23), or endarterectomy (1). Therapy was resumed in 24 patients (50%) after a mean lapse of 36 days. This was not possible in the remaining patients because of death or severe sequelae. New OACs (NOACs) were prescribed to 9 patients (18.7% of all potential candidates). At 3 months, patients with INR>1.7 in the acute phase exhibited better outcomes than patients with INR≤1.7 (mRS 0-2 in 62% vs 30.8%; death in 10% vs 38.4%; P=.0004). CONCLUSIONS Some patients taking OACs suffer ischaemic strokes that are usually cardioembolic, especially if INR is below the therapeutic range. OACs can be resumed without complications, and NOACs are still underused. Despite cases in which treatment is ineffective, outcomes are better when INR is above 1.7 at stroke onset.
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Affiliation(s)
- L M Cano
- Servicio de Neurología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España.
| | - P Cardona
- Servicio de Neurología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - H Quesada
- Servicio de Neurología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - B Lara
- Servicio de Neurología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
| | - F Rubio
- Servicio de Neurología, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, España
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Reviewing a Clinical Decision Aid for the Selection of Anticoagulation Treatment in Patients With Nonvalvular Atrial Fibrillation: Applications in a US Managed Care Health Plan Database. Clin Ther 2014; 36:1566-1573.e3. [DOI: 10.1016/j.clinthera.2014.09.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/13/2014] [Accepted: 09/17/2014] [Indexed: 12/28/2022]
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