Borne Ryan T, O'Donnell Colin, Turakhia Mintu P, Varosy Paul D, Jackevicius Cynthia A, Marzec Lucas N, Masoudi Frederick A, Hess Paul L, Maddox Thomas M, Ho P Michael
Division of Cardiology - Campus Box B130, University of Colorado Anschutz Medical Campus, 12631 E. 17th Avenue, Aurora, CO, 80045, USA.
VA Eastern Colorado Health Care System, Denver, CO, USA.
BMC Cardiovasc Disord. 2017 Sep 2;17(1):236. doi: 10.1186/s12872-017-0671-6.
The direct oral anticoagulants (DOACs) reduce the risk of stroke in moderate to high-risk patients with non-valvular atrial fibrillation (AF). Yet, concerns remain regarding its routine use in real world practice. We sought to describe adherence patterns and the association between adherence and outcomes to the DOACs among outpatients with AF.
We performed a retrospective cohort study of patients in the VA Healthcare System who initiated pharmacotherapy with dabigatran, rivaroxaban, or apixaban between November 2010 and January 2015 for non-valvular AF with CHADS-VASc score ≥ 2. Adherence was determined using pharmacy refill data and estimated by the proportion of days covered (PDC) over the first year of therapy. Clinical outcomes, including all-cause mortality and stroke, were measured at 6 months and used to assess measures of adherence for each DOAC.
A total of 2882 patients were included. Most were prescribed dabigatran (72.7%), compared with rivaroxaban (19.8%) or apixaban (7.5%). The mean PDC was 0.84 ± 0.20 for dabigatran, 0.86 ± 0.18 for rivaroxaban, and 0.89 ± 0.14 for apixaban (p < 0.01). The proportion of non-adherent patients, PDC <0.80, was 27.6% for all and varied according DOAC. Lower adherence to dabigatran was associated with higher risk of mortality and stroke (HR 1.07; 1.03-1.12 per 0.10 decline in PDC).
In a real-world VA population being prescribed anticoagulation for AF, more than one quarter had sub-optimal adherence. Lower adherence was associated with a higher risk of mortality and stroke. Efforts identifying non-adherent patients, and targeted adherence interventions are needed to improve outcomes.
直接口服抗凝剂（DOACs）可降低中度至高度风险的非瓣膜性心房颤动（AF）患者的中风风险。然而，在现实世界实践中对其常规使用仍存在担忧。我们试图描述AF门诊患者对DOACs的依从模式以及依从性与结局之间的关联。
我们对2010年11月至2015年1月期间在VA医疗保健系统中开始使用达比加群、利伐沙班或阿哌沙班进行药物治疗的非瓣膜性AF且CHADS-VASc评分≥2的患者进行了一项回顾性队列研究。使用药房配药数据确定依从性，并通过治疗第一年的覆盖天数比例（PDC）进行估计。在6个月时测量包括全因死亡率和中风在内的临床结局，并用于评估每种DOAC的依从性指标。
共纳入2882例患者。大多数患者被处方达比加群（72.7%），相比之下，利伐沙班为19.8%，阿哌沙班为7.5%。达比加群的平均PDC为0.84±0.20，利伐沙班为0.86±0.18，阿哌沙班为0.89±0.14（p<0.01）。所有患者中，PDC<0.80的非依从患者比例为27.6%，且因DOAC而异。达比加群依从性较低与更高的死亡率和中风风险相关（HR 1.07；PDC每下降0.10，HR为1.03-1.12）。
在接受AF抗凝治疗的现实世界VA人群中，超过四分之一的患者依从性欠佳。依从性较低与更高的死亡率和中风风险相关。需要努力识别非依从患者并进行有针对性的依从性干预以改善结局。
