scholarly journals Characterization of long-term oral anticoagulant adherence trajectories among patients with atrial fibrillation: a retrospective observational study

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
S Salmasi ◽  
A Safari ◽  
M De Vera ◽  
L Lynd ◽  
M Koehoorn ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulant ◽  
Information Criteria ◽  
Rapid Decline ◽  
First Year ◽  
Good Adherence ◽  
Slow Decline ◽  
Rolling Windows ◽  
Over Time

Abstract Background Medication taking is a dynamic behaviour that changes over time. Conventional adherence summary measures (e.g. proportion days covered) used in the OAC adherence studies conducted so far, however, are insensitive to the fluid nature of adherence. For example, identical PDC values can be calculated for patients with initial good adherence followed by poor adherence, and for those with periodic non-adherence throughout the course of therapy. Purpose The objective of this study was to characterize atrial fibrillation (AF) patients' long-term unique oral anticoagulant (OAC) adherence trajectories. Methods Using linked, population-based administrative data containing physician billings, hospitalization and prescription records of 4.8 million British Columbians (1996–2019), incident adult cases of AF were identified. Only patients who had prescription refill data available for five years were included in the analysis. The primary measure of OAC adherence was the proportion of days covered (PDC) over consecutive 90-day rolling windows. We modelled continuous 90-day PDC values over time. The time variable was number of years since OAC initiation. Group-Based Trajectory Modelling (GBTM) was used to identify patients' unique longitudinal adherence trajectories. To determine the best model, a relative comparison was done between models using Bayesian information criteria (BIC), and the Akaike information criterion (AIC). Results The study cohort was 19,749 AF patients [mean age 70.6y (SD 10.64), 56% male, mean CHA2DS2-VASc score 2.77 (SD 1.39]. The model that best fit our data identified four distinct OAC adherence trajectories (Figure). These were “consistent good adherence” (n=14,631 patients, 74.1% of the cohort), “rapid decline and discontinuation” (n=2327, 11.8%), “rapid decline with recovery” (n=1973, 9.99%), and “slow decline and discontinuation” (n=819, 4.2%). Our results show that there is heterogeneity among non-adherers. PDC dropped significantly in the first year after therapy initiation for those with “rapid decline and discontinuation” trajectory. Patients exhibiting “rapid decline with recovery” also displayed a rapid decline in adherence in the first year but showed improvements around the third year. Those in the “slow decline and discontinuation” trajectory displayed slow decline in adherence over first three years which eventually led to permanent discontinuation of therapy. Conclusion In this retrospective study we distinguished between the different kinds of non-adherence in terms of timing and rate. While a majority of our cohort adhered to their medications, we identified three unique trajectories displaying declining adherence over time at varying rates. Our results emphasize the importance of early intervention and have direct implications for improving the design of adherence interventions. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research grant

scholarly journals Comparative adherence between DOAC and VKA in patients with atrial fibrillation: a 23-year retrospective observational study in Canada

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
S Salmasi ◽  
A Safari ◽  
M.A De Vera ◽  
L Lynd ◽  
M Koehoorn ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Drug Class ◽  
Oral Anticoagulants ◽  
Current Evidence ◽  
Mixed Effect ◽  
Medication Discontinuation ◽  
The Impact ◽  
Rolling Windows ◽  
Over Time

Abstract Background A recent systematic review highlighted significant gaps in the evidence on atrial fibrillation (AF) patients' adherence to oral anticoagulants (OAC). Current evidence suffers from short follow-up times, focuses on the first OAC and does not take switching into account. There is also lack of observational data on adherence to warfarin due to its varying dose that complicates the calculations. As such there is lack of evidence on comparative adherence between VKAs and DOACs and whether the convenience of DOACs translates into better adherence in AF patients. Purpose Our objective was to measure AF patients' long-term OAC adherence and compare the impact of taking direct oral anticoagulants (DOAC) versus vitamin K antagonists (VKA) on adherence, while accounting for switching. Methods Using linked, population-based administrative data containing physician billings, hospitalization and prescription records of 4.8 million British Columbians (1996–2019), incident adult cases of AF were identified. The primary measure of adherence was proportion of days covered (PDC). Consecutive rolling 90-day windows were created for each patient starting from their first OAC prescription fill date until the end of their follow-up. The PDC for each 90-day rolling window was calculated and averaged to yield mean adherence over the follow-up period for each patient. Permanent medication discontinuation resulted in a PDC of 0 for all subsequent rolling windows after their supply ran out. As such, both poor execution and non-persistence were measured simultaneously. The association between drug class and adherence was assessed using generalized mixed effect linear regression models with drug class treated as time-varying covariate to account for switching. Results The study cohort was 30,264 AF patients [mean age 72.2 years (SD11.0), 44.6% female, mean CHA2DS2-VASc 2.94 (SD1.4)] with mean follow-up of 7.7 (SD 4.8) years. The mean PDC was 0.71 (SD 0.27) with 51% of the cohort having mean PDC values below the conventional threshold of adherence (PDC<0.8). Adherence dropped over time with the greatest decline in the first two years after therapy initiation. After controlling for all other confounders and accounting for switching, taking VKA compared to DOAC was, on average, associated with a 1-day decrease in number of days of medication-taking per year. Conclusion AF patients' OAC adherence was below the conventional threshold of 0.8, and dropped over time, particularly in the first two years. Drug class had no clinically meaningful impact on medication adherence. Our study highlights the need for effective adherence interventions particularly early in OAC therapy. Our findings also emphasizes that prescribers should not assume inherently better adherence for DOACs and should instead choose OAC in conversation with the patient and in accordance with their values and preferences. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research grant

The choice of an oral anticoagulant

1972 ◽  
Vol 10 (7) ◽  
pp. 25-28 ◽  
Keyword(s):  
Myocardial Infarction ◽  
Atrial Fibrillation ◽  
Anticoagulant Therapy ◽  
Cerebral Ischaemia ◽  
Oral Anticoagulant ◽  
Short Term ◽  
Prevention And Treatment ◽  
Transient Cerebral Ischaemia

Some of the indications for anticoagulant therapy remain controversial, but they are widely used for the prevention and treatment of thrombosis and embolism after surgery1 and after myocardial infarction,2 in patients with atrial fibrillation, and in those with transient cerebral ischaemia.3 This article discusses the drugs available for long-term use. Those suitable for immediate and short-term use, heparin and arvin, will be discussed in the next issue.

scholarly journals Mechanical thrombextraction in patient with acute ischemic stroke on background of oral anticoagulant therapy

2021 ◽  
pp. 36-40
Author(s):  
V.О. Yarosh ◽  
◽  
V.V. Babenko ◽  
O.E. Svyrydiuk ◽  
O.J. Zharinov ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Thrombolytic Therapy ◽  
Acute Ischemic Stroke ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulant ◽  
Oral Anticoagulant Therapy ◽  
Interventional Treatment ◽  
Key Words Ischemic Stroke

Thrombolytic therapy, which is a priority treatment strategy in patients with acute ischemic stroke in the first 3-4.5 hours after start of the disease, has significant limitations in case of background anticoagulant therapy. Mechanic thrombextraction is considered to be an alternative therapeutic strategy in case of inefficacy or contraindications to thrombolytic therapy. The article presents a clinical case of the 75-year old female patient with acute cardioembolic stroke on background of heart failure and atrial fibrillation. Long-term background usage of the direct oral anticoagulant due to atrial fibrillation is a limitation to use thrombolytic therapy, therefore mechanical thrombextraction was performed. The case presents possibilities of the successful interventional treatment of acute cardioembolic ischemic stroke. An example of a possible drug-drug interaction possibly leading to reduction of the effectiveness of anticoagulant therapy is shown. Key words: ischemic stroke, anticoagulants, mechanical trombextraction.

scholarly journals Improvement in A1c levels in early adulthood in the T1D Exchange: Impact of racial, socioeconomic, and clinical factors

2021 ◽  
Author(s):  
Elena Toschi ◽  
Ryan J Bailey ◽  
Kellee M Miller ◽  
Peter M Calhoun
Keyword(s):  
Higher Education ◽  
Glycemic Control ◽  
Early Adulthood ◽  
Rapid Decline ◽  
Stable Group ◽  
Gradual Decline ◽  
Slow Decline ◽  
High Hba1c ◽  
Very High ◽  
Over Time

Abstract Context Glycemic control in adolescents with type 1 diabetes is poor; yet, it typically improves during early adulthood. Factors related to improvement of glycemic control are unclear. Objective Examine how demographic and clinical variables may impact trajectories of glycemic control over time. Design Retrospective observational. Setting T1D Exchange clinic registry. Patients or Other Participants A total of 1,775 participants ages 18-30 years at enrollment. Main Outcome Measures Latent class trajectory modeling was used to determine sub-groups following a similar HbA1c trajectory over time. Results Five distinct trajectories of HbA1c classes were identified: “low-decline” and “moderate-decline” Groups had low or moderate HbA1c with a gradual decline, the “high-stable” Group had high HbA1c and remained stable, and the “very high-rapid decline” and “very high-slow decline” Groups had very high HbA1c with rapid or gradual decline. Compared with the “high-stable” Group, the “low-decline” and “moderate-decline” Groups were more likely to be male (P=0.009), white non-Hispanic (P=0.02), non-smokers (P<0.001), check self-monitoring blood glucose (SMBG) more frequently (P<0.001), and have higher education (P<0.001), lower BMI (P=0.02), and lower daily insulin dose (P<0.001). Compared with the “very high-rapid decline” and “very high-slow decline” Groups, “low-decline” and “moderate-decline” Groups were more likely to be male (p=0.02), have higher education (p<0.001), use insulin pumps (p=0.01), be non-smokers (p<0.001), and have a higher number of SMBG checks per day at enrollment (p<0.001). Conclusions We determined 5 distinct patterns of glycemic control from early adulthood into adulthood. Further evaluation into the modifiable factors associated with a declining HbA1c trajectory would aid in the development of targeted interventions.

scholarly journals Long-term blood pressure trajectories and incident atrial fibrillation in women and men: the Tromsø Study

2019 ◽  
Vol 41 (16) ◽  
pp. 1554-1562 ◽  
Author(s):  
Ekaterina Sharashova ◽  
Tom Wilsgaard ◽  
Jocasta Ball ◽  
Bente Morseth ◽  
Eva Gerdts ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Blood Pressure ◽  
Cox Regression ◽  
Exposure Period ◽  
Population Based ◽  
Hazard Ratios ◽  
Increased Risk ◽  
Mixed Modelling ◽  
Over Time

Abstract Aims To explore sex-specific associations between long-term individual blood pressure (BP) patterns and risk of incident atrial fibrillation (AF) in the general population. Methods and results Blood pressure was measured in 8376 women and 7670 men who attended at least two of the three population-based Tromsø Study surveys conducted in 1986–87, 1994–95, and 2001. Participants were followed for incident AF throughout 2013. Latent mixed modelling was used to identify long-term trajectories of systolic BP and hypertension. Cox regression was used to estimate associations between the identified trajectories and incident AF. Elevated systolic BP throughout the exposure period (1986–2001) independently and differentially increased risk of AF in women and men. In women, having elevated systolic BP trajectories doubled AF risk compared to having persistently low levels, irrespective of whether systolic BP increased, decreased, or was persistently high over time, with hazard ratios of 1.88 (95% confidence interval 1.37–2.58), 2.32 (1.61–3.35), and 1.94 (1.28–2.94), respectively. In men, those with elevated systolic BP that continued to increase over time had a 50% increased AF risk: 1.51 (1.09–2.10). When compared to those persistently normotensive, women developing hypertension during the exposure period, and women and men with hypertension throughout the exposure period had 1.40 (1.06–1.86), 2.75 (1.99–3.80), and 1.36 (1.10–1.68) times increased risk of AF, respectively. Conclusion Long-term BP and hypertension trajectories were associated with increased incidence of AF in both women and men, but the associations were stronger in women.

scholarly journals Compared with matched controls, patients with postoperative atrial fibrillation (POAF) have increased long-term AF after CABG, and POAF is further associated with increased ischemic stroke, heart failure and mortality even after adjustment for AF

2020 ◽  
Vol 109 (10) ◽  
pp. 1232-1242 ◽  
Author(s):  
Emma Thorén ◽  
Mona-Lisa Wernroth ◽  
Christina Christersson ◽  
Karl-Henrik Grinnemo ◽  
Lena Jidéus ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Observational Cohort Study ◽  
Postoperative Atrial Fibrillation ◽  
Observational Cohort ◽  
Over Time ◽  
Overall Mortality

Abstract Objective To analyze (1) associations between postoperative atrial fibrillation (POAF) after CABG and long-term cardiovascular outcome, (2) whether associations were influenced by AF during follow-up, and (3) if morbidities associated with POAF contribute to mortality. Methods An observational cohort study of 7145 in-hospital survivors after isolated CABG (1996–2012), with preoperative sinus rhythm and without AF history. Incidence of AF was compared with matched controls. Time-updated covariates were used to adjust for POAF-related morbidities during follow-up, including AF. Results Thirty-one percent of patients developed POAF. Median follow-up was 9.8 years. POAF patients had increased AF compared with matched controls (HR 3.03; 95% CI 2.66–3.49), while AF occurrence in non-POAF patients was similar to controls (1.00; 0.89–1.13). The observed AF increase among POAF patients compared with controls persisted over time (> 10 years 2.73; 2.13–3.51). Conversely, the non-POAF cohort showed no AF increase beyond the first postoperative year. Further, POAF was associated with long-term AF (adjusted HR 3.20; 95% CI 2.73–3.76), ischemic stroke (1.23; 1.06–1.42), heart failure (1.44; 1.27–1.63), overall mortality (1.21; 1.11–1.32), cardiac mortality (1.35; 1.18–1.54), and cerebrovascular mortality (1.54; 1.17–2.02). These associations remained after adjustment for AF during follow-up. Adjustment for other POAF-associated morbidities weakened the association between POAF and overall mortality, which became non-significant. Conclusions Patients with POAF after CABG had three times the incidence of long-term AF compared with both non-POAF patients and matched controls. POAF was associated with long-term ischemic stroke, heart failure, and corresponding mortality even after adjustment for AF during follow-up. The increased overall mortality was partly explained by morbidities associated with POAF. Graphic abstract

Weight and weight change and risk of atrial fibrillation: the HUNT study

2019 ◽  
Vol 40 (34) ◽  
pp. 2859-2866 ◽  
Author(s):  
Tingting Feng ◽  
Malmo Vegard ◽  
Linn B Strand ◽  
Lars E Laugsand ◽  
Bjørn Mørkedal ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Weight Change ◽  
Normal Weight ◽  
Hazard Ratios ◽  
Hunt Study ◽  
Average Body Mass ◽  
Average Body ◽  
Over Time

Abstract Aims Although obesity has been associated with risk of atrial fibrillation (AF), the associations of long-term obesity, recent obesity, and weight change with AF risk throughout adulthood are uncertain. Methods and results An ambispective cohort study was conducted which included 15 214 individuals. The cohort was created from 2006 to 2008 (the baseline) and was followed for incident AF until 2015. Weight and height were directly measured at baseline. Data on previous weight and height were retrieved retrospectively from measurements conducted 10, 20, and 40 years prior to baseline. Average body mass index (BMI) over time and weight change was calculated. During follow-up, 1149 participants developed AF. The multivariable-adjusted hazard ratios were 1.2 (95% confidence interval 1.0–1.4) for average BMI 25.0–29.9 kg/m2 and 1.6 (1.2–2.0) for average BMI ≥30 kg/m2 when compared with normal weight. The association of average BMI with AF risk was only slightly attenuated after adjustment for most recent BMI. In contrast, current BMI was not strongly associated with the risk of AF after adjustment for average BMI earlier in life. Compared with stable BMI, both loss and gain in BMI were associated with increased AF risk. After adjustment for most recent BMI, the association of BMI gain with AF risk was largely unchanged, while the association of BMI loss with AF risk was weakened. Conclusion Long-term obesity and BMI change are associated with AF risk. Obesity earlier in life and weight gain over time exert cumulative effects on AF development even after accounting for most recent BMI.

Sign in / Sign up

Export Citation Format

Share Document