Persistence and outcomes of non‐vitamin K antagonist oral anticoagulants versus warfarin in patients with non‐valvular atrial fibrillation

Abstract

Aims and objectives To compare persistence and outcomes of non‐vitamin K antagonist oral anticoagulants (NOACs) versus warfarin in Chinese patients with non‐valvular atrial fibrillation (AF). Background Given the unpredictable warfarin response and the costliness of NOACs, more research is needed to clarify which drug enjoys better persistence and outcomes, helping to provide personalised care for patients. Design A prospective cohort study. Methods Chinese patients taking NOACs or warfarin from March 2016–April 2018 were followed up by telephone or outpatient visit at 3, 6 months and half a year thereafter. Anticoagulant persistence and outcomes including stroke and bleeding were collected. We used Cox regression to analyse data. This study was reported according to the STROBE guideline. Results A total of 344 patients were enrolled; 146 patients received NOACs including dabigatran and rivaroxaban, and 198 patients received warfarin. Persistence with anticoagulants was low and dropped sharply at the third month. Patients on NOACs had worse persistence at 3, 6 and 12 months than those on warfarin. There was no difference in the incidence of ischaemic stroke and bleeding between groups, although ischaemic stroke and major bleeding occurred less frequently in the NOACs group. Paroxysmal AF, no heart failure and no stroke were predictors of NOACs non‐persistence. Prior catheter ablation and no diabetes were associated with poor persistence of warfarin. The main reason for anticoagulant cessation was patient preference. Conclusions Chinese patients taking NOACs had lower persistence, similar rate of ischaemic stroke and bleeding compared with those on warfarin. Further inventions are needed to improve persistence in Chinese patients on NOACs. Relevance to clinical practice Anticoagulation should highlight both persistence and outcomes emphasising personalised care of different drugs. Further interventions to improve persistence should be developed based on causes and risk factors and carried out in the third month of therapy.

A retrospective cohort study of oral anticoagulant treatment in patients with acute coronary syndrome and atrial fibrillation

“…Compared with warfarin, NOACs are more convenient to use, including advantages such as fixed dose regimens, no requirement for frequent blood monitoring, no food and drug restrictions and less risk of bleeding 26 27. In the current study, we found that there was a substantially increased use of NOACs in Chinese patients during the past few years.…”

The role of patient preferences in adherence to treatment in chronic disease: a narrative review

“…Wu et al compared persistence and outcomes of non-vitamin K antagonist oral anticoagulants (NOACs) to warfarin. Patients on NOACs were seen to have worse persistence at 3, 6, and 12 months than those on warfarin; the main reasons for anticoagulant discontinuation cited were related to patient preference such as adverse bleeding events and costs (33).…”

“…In the study on atrial fibrillation by Wu et al, persistence to therapy with anticoagulants was strongly influenced by costs, as well as with adverse events to treatment (33). Indeed, patients prescribed NOACs had worse persistence than those given warfarin and the study was carried out in China where, as noted by the authors, NOACs are approximately 80 times more expensive than warfarin, which influences not only preference, but the ability to acquire the drug.…”

Bleeding Risk in Nonvalvular Atrial Fibrillation Patients Receiving Direct Oral Anticoagulants and Warfarin: A Systematic Review and Meta-Analysis of Observational Studies

“…The initial literature search identified 3,359 potentially eligible citations. After primary screening, 150 articles were eligible for full-text review and there were 35 studies 7 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 including 2,356,201 patients that met the inclusion criteria and presented relevant data regarding major bleeding and clinically relevant bleeding ( Fig. 1 ).…”