Abstract Number: PB2047
Meeting: ISTH 2020 Congress
Background: Direct oral anticoagulants (DOACs) are used for thromboembolic stroke prevention in patients with non-valvular atrial fibrillation (AF), but their effectiveness is expected to depend on drug persistence.
Aims: To study the association between non-persistence to DOACs and thromboembolic stroke risk among AF patients.
Methods: With nationwide statistics we identified and followed all AF patients who started DOAC treatment between January 2013-September 2017. Non-persistence was defined according to the last DOAC prescription during follow-up, using a 100-day gap and allowing a switch to vitamin K antagonists. With time-dependent Cox modelling, we estimated the risk of thromboembolic stroke/death due to ischemic stroke (composite outcome) associated with non-persistence. Adjustments were made for age, sex, VKA history, stroke history, AF type, and household income. In addition, a stratified analysis based on CHA2DS2-VASc >2 was performed. According to guidelines, AF patients with a score of < 2 who are converted to sinus rhythm may discontinue anticoagulation contrary to those with high CHA2DS2-VASc scores.
Results: 70574 incident DOAC users with AF were included; mean age was 71.4 years, 57%(n=40318) were men and 49%(n=34272) had a CHA2DS2-VASc >2. The cumulative incidence of non-persistence was 42% at 4 years follow-up and the overall incidence of the composite outcome was 1.08% (95%CI,1.01-1.14) per year. The adjusted hazard ratio [AHR] for the composite outcome was 1.69 (95%CI,1.31-2.18) for those who were non-persistent to DOAC (Table). Subgroup analyses suggested that those with CHA2DS2-VASc 0-2 who were non-persistent had a lower risk of the composite outcome (HR 0.71; 95%CI,0.48-1.04) compared to persistent patients. However, patients with CHA2DS2-VASc >2 who were non-persistent to DOAC had high risks of the composite outcome, compared to persistent patients (HR 2.51; 95%CI,1.87-3.35 and 2.46;1.76-3.42, for CHA2DS2-VASc score 3-4 and CHA2DS2-VASc score >5, respectively).
Conclusions: Non-persistence to DOAC was associated with an increased risk of thromboembolic stroke in Dutch non-valvular AF patients.
|Observation years||No. of events||adjusted HR (95%CI) (age and sex)||adjusted HR (95%CI) (all variables)||HR (95%CI); CHA2DS2-VASc 0-2||HR (95%CI); CHA2DS2-VASc 3-4||HR (95%CI); CHA2DS2-VASc ≥ 5|
|Persistent||96789||1037||1 (reference)||1 (reference)||1 (reference)||1 (reference)||1 (reference)|
|Non-persistent||10982||123||1.64 (1.36-1.98)||1.69 (1.31-2.18)||0.71 (0.48-1.04)||2.51 (1.87-3.35)||2.46 (1.76-3.42)|
[Table 1. Non-persistence to DOAC in relation to the composite outcome (ischemic stroke and ischemic stroke-related mortality)]
To cite this abstract in AMA style:Toorop MMA, Chen Q, Tichelaar V, Cannegieter SC, Lijfering WM. Non-Persistence to Direct Oral Anticoagulants and Risk of Thromboembolic Stroke among Patients with Non-Valvular Atrial Fibrillation: A Dutch Nationwide Cohort Study [abstract]. Res Pract Thromb Haemost. 2020; 4 (Suppl 1). https://abstracts.isth.org/abstract/non-persistence-to-direct-oral-anticoagulants-and-risk-of-thromboembolic-stroke-among-patients-with-non-valvular-atrial-fibrillation-a-dutch-nationwide-cohort-study/. Accessed December 5, 2021.
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