Reasons for Discontinuing Oral Anticoagulation Therapy for Atrial Fibrillation

A Systematic Review

Jackie Buck; Julia Fromings Hill; Alison Martin; Cassandra Springate; Bikramaditya Ghosh; Rachel Ashton; Gerry Lee; Andrzei Orlowski

Disclosures

Age Ageing. 2021;50(4):1108-1117. 

In This Article

Abstract and Introduction

Abstract

Introduction: Atrial fibrillation (AF) is the most common cardiac arrhythmia and can lead to significant comorbidities and mortality. Persistence with oral anticoagulation (OAC) is crucial to prevent stroke but rates of discontinuation are high. This systematic review explored underlying reasons for OAC discontinuation.

Methods: A systematic review was undertaken to identify studies that reported factors influencing discontinuation of OAC in AF, in 11 databases, grey literature and backwards citations from eligible studies published between 2000 and 2019. Two reviewers independently screened titles, abstracts and papers against inclusion criteria and extracted data. Study quality was appraised using Gough's weight of evidence framework. Data were synthesised narratively.

Results: Of 6,619 sources identified, 10 full studies and 2 abstracts met the inclusion criteria. Overall, these provided moderate appropriateness to answer the review question. Four reported clinical registry data, six were retrospective reviews of patients' medical records and two studies reported interviews and surveys. Nine studies evaluated outcomes relating to dabigatran and/or warfarin and three included rivaroxaban (n = 3), apixaban (n = 3) and edoxaban (n = 1). Bleeding complications and gastrointestinal events were the most common factors associated with discontinuation, followed by frailty and risk of falling. Patients' perspectives were seldom specifically assessed. Influence of family carers in decisions regarding OAC discontinuation was not examined.

Conclusion: The available evidence is derived from heterogeneous studies with few relevant data for the newer direct oral anticoagulants. Reasons underpinning decision-making to discontinue OAC from the perspective of patients, family carers and clinicians is poorly understood.

Introduction

Atrial fibrillation (AF) is a cardiac rhythm disorder that increases mortality and morbidity due to thromboembolic events such as stroke and myocardial infarction.[1,2] The risk of mortality and morbidity due to AF increases with age, with incidence being highest among people older than 75 years and mortality being around 15% in these patients.[1,3] The prevalence of AF has risen particularly in higher-income countries.[4] The projected prevalence of AF is expected to triple in the next 10–20 years, possibly reaching around 9 million in the USA by 2030[5] and 18 million in Europe by 2060.[6]

International guidelines, such as those from the American Heart Association/American College of Cardiology/Heart Rhythm Society[7] and the European Society of Cardiology,[8] and the UK national guidelines from the National Institute of Health and Care Excellence[9] recommend the use of oral anticoagulation (OAC) as a preventive measure against stroke. Use of OAC significantly reduces the chances of thromboembolic cardiovascular events, such as stroke, and mortality in patients with non-valvular AF.[10]

Two main groups of oral anticoagulant drugs are used to treat AF: vitamin K antagonists ([VKAs] most commonly warfarin) and non-VKAs, also known as direct oral anticoagulants (DOACs), including dabigatran, apixaban, rivaroxaban and edoxaban. A meta-analysis of the efficacy of OAC for stroke prevention in AF concluded that DOACs were more effective and cost-effective than warfarin.[11] However, despite being highly effective in reducing and preventing stroke and embolism in clinical trials, in real-world settings, the efficacy of treatments depends greatly on medication being prescribed and taken as recommended. Persistence rates with OAC vary but are typically around 15–20%.[12,13] The patterns of persistence and adherence rates also differ by drug type, with studies indicating differences in patients' preferences for warfarin or DOACs.[14,15]

Discontinuing treatment can have negative consequences, including increased disease burden. In accordance, the risk of hospitalisation and higher total health-care costs rise.[2,16] Understanding the reasons why patients discontinue OAC is essential to tackling these issues.

The aim of this study was to determine the reasons that OAC is permanently discontinued, with a focus on patient, clinician and family/carer perspectives.

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