School of Mathematics, Statistics, and Computer Science, College of Science University of Tehran Iran.
Faculty of Applied Science University of British Columbia Vancouver Canada.
J Am Heart Assoc. 2024 Sep 17;13(18):e035639. doi: 10.1161/JAHA.124.035639. Epub 2024 Sep 9.
Patients with atrial fibrillation are frequently nonadherent to oral anticoagulants (OACs) prescribed for stroke and systemic embolism (SSE) prevention. We quantified the relationship between OAC adherence and atrial fibrillation clinical outcomes using methods not previously applied to this problem.
Retrospective observational cohort study of incident cases of atrial fibrillation from population-based administrative data over 23 years. The exposure of interest was proportion of days covered during 90 days before an event or end of follow-up. Cox proportional hazard models were used to evaluate time to first SSE and the composite of SSE, transient ischemic attack, or death and several secondary outcomes. A total of 44 172 patients were included with median follow-up of 6.7 years. For direct OACs (DOACs), each 10% decrease in adherence was associated with a 14% increased hazard of SSE and 5% increased hazard of SSE, transient ischemic attack, or death. For vitamin K antagonist (VKA) the corresponding increase in SSE hazard was 3%. Receiving DOAC or VKA was associated with primary outcome hazard reduction across most the proportion of days covered spectrum. Differences between VKA and DOAC were statistically significant for all efficacy outcomes and at most adherence levels.
Even small reductions in OAC adherence in patients with atrial fibrillation were associated with significant increases in risk of stroke, with greater magnitudes for DOAC than VKA. DOAC recipients may be more vulnerable than VKA recipients to increased risk of stroke and death even with small reductions in adherence. The worsening efficacy outcomes associated with decreasing adherence occurred without the benefit of major bleeding reduction.
患有心房颤动的患者经常不遵守处方的口服抗凝剂（OAC）来预防中风和全身性栓塞（SSE）。我们使用以前未应用于该问题的方法来量化 OAC 依从性与心房颤动临床结果之间的关系。
对 23 年来基于人群的行政数据中发生的心房颤动事件的回顾性观察性队列研究。感兴趣的暴露是事件前 90 天或随访结束前的覆盖率比例。Cox 比例风险模型用于评估首次发生 SSE 的时间以及 SSE、短暂性脑缺血发作或死亡的复合终点以及几个次要结局。共纳入 44172 例患者，中位随访时间为 6.7 年。对于直接口服抗凝剂（DOAC），依从性每降低 10%，SSE 风险增加 14%，SSE、短暂性脑缺血发作或死亡风险增加 5%。对于维生素 K 拮抗剂（VKA），SSE 风险的相应增加为 3%。接受 DOAC 或 VKA 与大多数覆盖比例范围内的主要结局风险降低相关。在大多数依从性水平下，VKA 和 DOAC 之间的差异在所有疗效结果上均具有统计学意义。
即使在患有心房颤动的患者中，OAC 依从性略有降低，也与中风风险显著增加相关，与 VKA 相比，DOAC 的幅度更大。即使依从性略有降低，DOAC 接受者可能比 VKA 接受者更容易出现中风和死亡风险增加。与依从性降低相关的疗效结果恶化并没有带来大出血减少的益处。
