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Lower-adherence direct oral anticoagulant use is associated with increased risk of thromboembolic events than warfarin

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Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Abstract

Background

Real-world data have suggested inconsistent adherence to oral anticoagulation for thromboembolic event (TE) prevention in patients with Non valvular atrial fibrillation (NVAF), yet it remains unclear if event risk is elevated during gaps of non-adherence.

Objective

To compare difference in outcomes between direct oral anticoagulant (DOAC) and warfarin based on adherence to the therapy in patients with NVAF.

Methods

Using the MarketScan claims data, patients receiving prescription of warfarin or a DOAC for NVAF from January 2015 to June 2016 were included. Outcomes included hospitalization for TE (ischemic stroke or systemic embolism), hemorrhagic stroke, stroke of any kind, and major bleeding. Event rates were reported for warfarin and DOACs at a higher-adherence proportion of days covered (PDC > 80%) and lower-adherence (PDC 40–80%).

Results

The cohort included 83,168 patients prescribed warfarin (51% [n = 42,639]) or DOAC (49% [n = 40,529]). Lower adherence occurred in 36% (n = 15,330) of patients prescribed warfarin and 26% (n = 10,956) prescribed DOAC. As compared to higher-adherence warfarin after multivariable adjustment, the risk of TE was highest in lower-adherence DOAC (HR 1.26; 95% CI, 1.14–1.33), and lowest in higher-adherence DOAC (HR, 0.93; 95% CI, 0.88–0.99). There was a significantly higher risk of hemorrhagic stroke and stroke of any kind in the lower-adherence groups. Major bleeding was more common with lower-adherence DOAC (HR, 1.43, 95% CI, 1.35–1.52) and lower-adherence warfarin (HR, 1.32, 95% CI, 1.26–1.39).

Conclusions

In this large real-world study, low adherence DOAC was associated with higher risk of TE events as compared to high and low adherence warfarin.

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Data availability

The data that support the findings of this study are available from the corresponding author (DJL), upon request.

Abbreviations

AF:

Atrial fibrillation

AC:

Anticoagulation

DOAC:

Direct oral anticoagulants (Apixaban, Rivaroxaban, Dabigatran, and Edoxaban)

TE:

Thromboembolism

PDC:

Proportion of days covered

NVAF:

Non-valvular atrial fibrillation

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Authors and Affiliations

  1. The Kansas City Heart Rhythm Institute (KCHRI) @ HCA Midwest, the University of Missouri – Columbia, 12200, W 106Th Street, Overland Park Regional Medical Center, Overland Park, KS, 66215, USA

    Danish Bawa, Douglas Darden, Adnan Ahmed, Rajesh Kabra, Krishna Pothineni, Rakesh Gopinathannair & Dhanunjaya Lakkireddy

  2. Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, CA, USA

    Jalaj Garg

  3. Synchron, New York City, NY, USA

    Edward Karst

  4. Massachusetts General Hospital, Boston, MA, USA

    Moussa Mansour

  5. Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA

    Jeffrey Winterfield

Authors
  1. Danish Bawa
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Correspondence to Dhanunjaya Lakkireddy.

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Key Points

Question: Is there a difference in the outcomes of anticoagulation between DOAC and warfarin based on adherence among patients with non-valvular atrial fibrillation (NVAF)

Findings: This real-world study using the MarketScan claims data included 83,168 patients with NVAF, multi-regression analysis showed increased thromboembolic events in low adherence DOAC as compared to high adherence warfarin.

Meaning: Although DOACs are considered superior to warfarin in the management of NVAF, low adherence to therapy may change this effect and lead to worse outcomes as compared to warfarin.

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Bawa, D., Darden, D., Ahmed, A. et al. Lower-adherence direct oral anticoagulant use is associated with increased risk of thromboembolic events than warfarin. J Interv Card Electrophysiol (2023). https://doi.org/10.1007/s10840-023-01585-x

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