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Cardio Metabolic

Enhancing adherence to anticoagulant therapy in atrial fibrillation

  • Non-adherence to Non-Vitamin K Oral Anticoagulant (NOAC) therapy can lead to severe complications, influenced by patient, physician, and healthcare system factors.
  • Patient education and behavioral interventions are key to ensuring adherence to NOAC treatment.
  • Strategies for optimizing adherence include patient engagement, personalized care, regular follow-ups, and addressing fear of bleeding.
  • Healthcare professionals play a pivotal role in enhancing adherence through strong patient-provider relationships and clear communication.

Understanding atrial fibrillation and NOAC therapy

Atrial Fibrillation (AF), a prevalent cardiac condition affecting approximately 2.3 million Americans, is characterized by an irregular and often rapid heart rate. This condition significantly increases the risk of stroke, heart failure, and other heart-related complications. The advent of Non-Vitamin K Oral Anticoagulants (NOACs): dabigatran, rivaroxaban, apixaban, and edoxaban – offers several advantages over warfarin. These include straightforward dosing regimens, no need for monitoring, and a reduced risk of intracranial hemorrhage. Despite NOACs’ benefits and anticipated adoption, under-treatment remains a challenge in new AF patients.

While evidence, bolstered by meta-analyses, suggests that NOAC should be the preferred oral anticoagulant (OAC), the persistent under-treatment of AF, despite effective therapies, underscores the need for new strategies to improve physician knowledge and practice. To enhance the quality of AF care, comprehensive educational programs for AF patients are being introduced. Non-adherence increases the risk of ischaemic and haemorrhagic complications, other adverse cardiovascular events, and overall mortality. This can lead to poor health outcomes and higher healthcare costs. Given the shorter elimination half-lives of NOACs compared to warfarin, strict adherence to NOAC therapy is essential.1-3

The importance of adherence to NOAC therapy

Non-Vitamin K antagonist Oral anticoagulant (NOAC) therapy, a popular choice for stroke prevention in AF patients, necessitates strict adherence due to its shorter elimination half-lives and short duration of anticoagulant effect. Non-adherence and non-persistence to NOAC therapy can lead to both ischemic and hemorrhagic complications, adverse cardiovascular events, and increased mortality, resulting in poor health outcomes and elevated healthcare costs.

Studies have shown that the overall mean adherence to NOACs in AF patients is 77%, with 66% of patients demonstrating good adherence. However, non-adherence was associated with an almost 40% increased risk of stroke, and non-persistence was linked to an almost five-fold increased risk of stroke/transient ischemic attack. Therefore, patient education and behavioral interventions are crucial for NOAC treatment success. Patients need to be informed about their condition, treatment options, risks and benefits of treatment, potential consequences of non-adherence, and the importance of strict adherence to the prescribed regimen. Regular patient review is essential to identify non-adherence and implement strategies to improve adherence. Optimizing adherence to NOAC therapy is of paramount importance in managing AF, and efforts should be made to identify and address factors affecting adherence and persistence to NOAC therapy.1-2

Adherence measurement techniques have been discussed in our article- Measuring adherence – an “Achilles heel” in medication adherence

Challenges in adherence to NOAC therapy

Non-adherence to NOACs can lead to increased risk of both ischemic and hemorrhagic complications, adverse cardiovascular events, and all-cause mortality, translating into poor health outcomes and increased healthcare costs. Factors influencing adherence to NOAC therapy are multifactorial and include patient-related, physician-related, and healthcare system-related factors.4

Patient-related factors influencing non-adherence to NOACs: include younger age, lower socioeconomic status, lack of information about their disease and medications, depressive symptoms, psychiatric illness, cognitive impairment, frailty and risk of falling, comorbidity burden and impaired quality of life, lack of social support, alcohol, and drug abuse. Cultural and geographical background of the patient, polypharmacy, fear of bleeding, and worries about worsening health outcomes also play a role. The complexity of the regimen, the impact on daily routine and lifestyle restrictions, and the fear of bleeding are other factors that limit adherence to therapy.1

Physician-related factors influencing non-adherence to NOACs: include overestimation of bleeding risk, which often outweighs their concern about the risk of stroke. The healthcare system also plays a role, with the lack of required ongoing coagulation monitoring diminishing clinician oversight of therapeutic regimens, requiring a greater effort in patient education and monitoring for adherence.

Non-adherence to NOAC therapy can have severe consequences, including increased risk of stroke, death, and higher medical costs. Therefore, it is essential to ensure that drugs are taken according to the prescribed regimen, and that patients are appropriately informed about their condition, treatment options, how to adhere to treatment, risks and benefits of treatment, potential consequences of non-adherence, and managing patient’s expectations.1

Table1: Factors influencing adherence and persistence to NOAC therapy1

FactorsDescription
Patient-related factorsYounger patients, lower socioeconomic status, less informed about disease and medications, depressive symptoms or pessimistic attitude, psychiatric illness, cognitive impairment, frailty and risk of falling, comorbidity burden, impaired quality of life, lack of social support, alcohol and drug abuse, male gender, living alone, cultural and geographical background, active employment, busy work schedules, frequent social activities, greater education, patient-perceived treatment burden, impact on daily routine and lifestyle restrictions
Therapy-related factorsPolypharmacy, especially when including antiplatelet drugs or more complex drug regimens, fear of bleeding, worries about worsening health outcomes, complexity of the regimen
Healthcare system-related factorsAccess to healthcare, cost of medication, lack of follow-up, lack of healthcare professional time, lack of integrated care
Disease-related factorsSymptom burden, disease severity, type of AF (paroxysmal, persistent, permanent), comorbidities, risk of stroke and bleeding
Treatment-related factorsPrevious experience with vitamin K antagonist (VKAs), time in therapeutic range with VKAs, side effects, drug-drug interactions, dosing frequency, need for dose adjustment, need for renal function monitoring

Some practical scenarios for non-adherence to NOAC therapy1,4

  • Overestimation of Bleeding Risks: Physicians often overestimate the risk of bleeding, leading to hesitancy in prescribing NOACs.
  • Major Bleed Apprehension: The fear of being responsible for a major bleed can overshadow the recognized benefits of stroke prevention.
  • Stroke Prevention vs. Bleeding Risk: Clinicians should prioritize stroke prevention, as its benefits typically outweigh bleeding risks.
  • Reversible Bleeding Risk Factors: Instead of limiting NOAC therapy, it’s crucial to identify and address reversible bleeding risk factors highlighted in bleeding scores.
  • The EuroObservational Research Programme Pilot survey on Atrial Fibrillation (EORP-AF Pilot) General Registry Findings: According to this registry, only 60% of patients received OAC treatment aligned with current guidelines.
  • Factors Influencing Non-Adherence: Several factors can deter physicians from adhering to guidelines when prescribing NOACs, including:
    • Geographical region
    • Observation setting
    • Patient’s advanced age
    • Male gender
    • Presence of comorbidities (some of which are reflected in the Congestive heart failure, Hypertension, Age ≥75 years (doubled), Diabetes mellitus, prior Stroke or TIA or thromboembolism (doubled) score (CHA2DS2-VASc))
    • Specific clinical presentations
    • History of pharmacological cardioversion.

Strategies for optimizing adherence to NOAC therapy

Strategies for optimizing adherence to NOAC therapy are multifaceted and require a patient-centered approach. Ensuring patients are appropriately informed about their condition, treatment options, how to adhere to treatment, risks and benefits of treatment, potential consequences of non-adherence, in addition to managing patient’s expectations, are crucial to NOAC treatment success. Regular patient review is crucial to identify non-adherence and implement strategies to improve adherence. The need for NOAC therapy and the importance of strict and sustained adherence must be thoroughly explained to the patient, so that the patient will be able to understand the potential consequences of non-adherence.

Information should be provided using appropriate language, in a variety of formats, and confirmation of patients’ understanding should be checked. The mode of delivery and complexity of information should be adapted to the individual patient. Many simultaneous approaches can help the clinician providing straightforward information, including leaflets, a patient anticoagulation card, group sessions, and online patient support websites. Patient engagement and shared decision-making are also integral to improving adherence. The decision of whether to initiate NOAC therapy, and which anticoagulant to use, should be made by the treating clinician after consultation with the patient. Patient’s values, goals, and preferences should guide shared decision-making. A good physician–patient relationship and communication is required for good patient adherence and persistence with NOACs.

The decision to initiate NOAC therapy and the choice of anticoagulant should be a collaborative effort between the clinician and the patient, considering the patient’s values, goals, and preferences. Patients desire active involvement in their care decisions and seek reassurance about diagnosis and treatment. Effective physician-patient communication is essential for adherence to NOACs. By actively engaging patients and addressing their concerns and beliefs, healthcare professionals can enhance patient understanding of their condition, therapeutic options, and the significance of OAC therapy, enabling them to make well-informed healthcare decisions.1,5

Other digital intervention to enhance adherence has been covered in our article on Mobile apps for enhancing adherence to chronic diseases

Approaches to enhance adherence with NOAC regimens in atrial fibrillation management:1,5

1. Patient engagement and shared decision-making: The decision of whether to initiate NOAC therapy, and which anticoagulant to use, should be made by the treating clinician after consultation with the patient. Patients’ values, goals, and preferences should guide shared decision-making. A good physician–patient relationship and communication is required for good patient adherence and persistence with NOACs.

2. Patient education and behavioral interventions: Ensuring patients are appropriately informed about their condition, treatment options, how to adhere to treatment, risks and benefits of treatment, potential consequences of non-adherence, in addition to managing patient’s expectations, are crucial to NOAC treatment success. Regular patient review is crucial to identify non-adherence and implement strategies to improve adherence.

3. Use of adherence aids: Many simultaneous approaches can help the clinician providing straightforward information, including leaflets, a patient anticoagulation card, group sessions, and online patient support websites. It is important to utilize each patient visit and every prescription renewal for re-education, discussing intake modalities, the importance of strict adherence to the prescribed dosing regimen to reduce the likelihood of serious adverse events and to convince patients that NOACs therapy should not be discontinued.

4. Personalized care: Information should be provided using appropriate language, in a variety of formats, and confirmation of patients’ understanding should be checked. The mode of delivery and complexity of information should be adapted to the individual patient.

5. Regular follow-ups: Regular scheduled contact with healthcare professionals, patient anticoagulation card recordings, and an active multidisciplinary approach have been proposed to improve patient’s adherence.

6. Addressing fear of bleeding: The fear of bleeding still has a major impact on patient adherence to NOAC therapy. However, proper education and shared decision-making can overcome this barrier, since AF patients are willing to accept certain bleeding risks for a decrease in the probability of experiencing a stroke.

7. Addressing specific knowledge gaps: Education may be more effective if directed to specific knowledge gaps of the patient, which can be measured by validated questionnaires. Educational group sessions, tailored to each NOAC and considering social, ethnic, cultural, and geographical differences may be developed to improve adherence to NOACs.

In conclusion, Atrial Fibrillation (AF) is a major health issue that necessitates effective management to avert serious complications, notably stroke. Non-Vitamin K antagonist Oral anticoagulant (NOAC) therapy has become a favored treatment due to its benefits over traditional Vitamin K antagonists. However, the efficacy of NOAC therapy hinges on patient adherence. Recognizing the elements that impact adherence, such as patient awareness, apprehension of bleeding, and regimen complexity, is vital. Addressing these elements through patient education, routine follow-ups, and personalized care can markedly enhance adherence rates.

Furthermore, the role of healthcare professionals is pivotal. Their capacity to cultivate a strong patient-provider relationship, involve patients in shared decision-making, and provide lucid and comprehensible information can significantly boost adherence to NOAC therapy. In the face of obstacles, it’s crucial to remember that each patient is unique, and strategies should be customized to meet individual needs. By optimizing adherence to NOAC therapy, we can enhance health outcomes for AF patients and alleviate the strain on healthcare systems. As we continue to gain more knowledge about AF and NOAC therapy, we hope these insights will steer future research and practice, ultimately improving the quality of life for patients with AF.1,6-7

“Health is the greatest gift, contentment the greatest wealth, faithfulness the best relationship.” – Buddha

References

  1. Farinha JM, Jones ID, Lip GY. Optimizing adherence and persistence to non-vitamin K antagonist oral anticoagulant therapy in atrial fibrillation. Eur Heart J Suppl. 2022;24(Supplement_A):A42-55.
  2. Angiolillo DJ, Bhatt DL, Cannon CP, Eikelboom JW, Gibson CM, Goodman SG, Granger CB, Holmes DR, Lopes RD, Mehran R, Moliterno DJ. Antithrombotic therapy in patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention: a North American perspective: 2021 update. Circulation. 2021;143(6):583-96.
  3. Kirley K, Bauer V, Masi C. The role of NOACs in atrial fibrillation management: a qualitative study. J. Atr. Fibrillation. 2016;9(1).
  4. Salmasi S, Loewen PS, Tandun R, Andrade JG, De Vera MA. Adherence to oral anticoagulants among patients with atrial fibrillation: a systematic review and meta-analysis of observational studies. BMJ open. 2020;10(4):e034778.
  5. Lip GY, Lane DA, Potpara TS. Innovative strategies to improve adherence to non-vitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation. Eur. Heart J. 2018;39(16):1404-6.
  6. Guo Y, Lane DA, Wang L, Zhang H, Wang H, Zhang W, Wen J, Xing Y, Wu F, Xia Y, Liu T. Mobile health technology to improve care for patients with atrial fibrillation. J. Am. Coll. Cardiol. 2020 Apr 7;75(13):1523-34.
  7. Ozaki AF, Choi AS, Le QT, Ko DT, Han JK, Park SS, Jackevicius CA. Real-world adherence and persistence to direct oral anticoagulants in patients with atrial fibrillation: a systematic review and meta-analysis. Circ.: Cardiovasc. Qual.. 2020 Mar;13(3):e005969.