Predicted adherence and ischaemic stroke risk in atrial fibrillation patients initiating oral anticoagulation: A cohort study of the medication adherence score.
Jul 2026· International Journal of Cardiology· Vol 461, pp.
134660
· 0 citations· 30 references
Medicine
TL;DR
In AF patients initiating OAC, low predicted medication adherence is independently associated with increased ischaemic stroke risk, and the MAS may support early identification of high-risk patients, enabling targeted adherence interventions at OAC initiation.
Abstract
Background
Medication non-adherence is a major challenge in stroke prevention in atrial fibrillation (AF), yet no validated tool exists to identify patients at risk of non-adherence at the time of oral anticoagulation (OAC) initiation.
Methods
In this retrospective cohort study at a large tertiary centre in New York City (2015-2023), adults with AF and a CHA₂DS₂-VASc score ≥ 2 initiating OAC were included. Predicted medication adherence was quantified using the Medication Adherence Score (MAS), a validated algorithm incorporating demographic, socioeconomic, and geographic attributes, dichotomised as high (MAS ≥80) or low (MAS <80). The primary outcome was ischaemic stroke within 12 months, analysed using Fine-Gray competing-risk regression.
Results
Of 11,233 eligible patients, 4035 (35.9%) had high and 7198 (64.1%) had low predicted adherence. Most patients received a direct oral anticoagulant (DOAC, 70.3%), 10.7% received warfarin, and 19.0% switched agents. Ischaemic stroke occurred in 6.2% of patients. High predicted adherence was associated with significantly lower stroke risk (sHR 0.67; 95% CI 0.56-0.80), with 12-month cumulative incidences of 5.08% vs. 7.97%. Continuously modelled MAS confirmed a dose-response relationship (HR 0.98 per unit increase; 95% CI 0.97-0.99). Results were consistent after excluding patients with prior stroke (sHR 0.66; 95% CI 0.53-0.83).
Conclusions
In AF patients initiating OAC, low predicted medication adherence is independently associated with increased ischaemic stroke risk. The MAS may support early identification of high-risk patients, enabling targeted adherence interventions at OAC initiation.
BACKGROUND
Patients with atrial fibrillation (AF) who are at increased risk of both thrombotic and haemorrhagic events represent a heterogeneous and broad clinical entity, characterized by the presence of several Janus-faced risk factors. We aimed to identify clinical phenotypes and assess the association of ABC pathway adherence with one-year outcomes in patients with AF at high risk of both stroke and bleeding.
METHODS
AF patients who had HAS-BLED score ≥3 and CHA2DS2-VASc score ≥2 were included. Hierarchical clustering was applied to identify phenotypic subgroups. We assessed the impact on net adverse clinical event (NACE) of adherence to the integrated care based on the Atrial fibrillation Better Care (ABC) pathway.
RESULTS
A total of 2,535 patients (mean age 75.4 ± 7.8 years; 58.3% male) were enrolled. Cluster I had the highest rates of prior thromboembolic and haemorrhagic events with the lowest comorbidity burden; Cluster II comprised the oldest patients with the highest prevalence of dyslipidaemia, heart failure, and peripheral artery disease; Cluster III was the youngest with the highest BMI and alcohol use. Cluster II (aOR 1.93, 95% CI 1.37-2.78), and Cluster III (aOR 1.65, 95% CI 1.10-2.50) were associated with a higher risk of all-cause death compared to Cluster I. Among patients with available ABC pathway data, adherence was associated with lower odds of 1-year MACE (OR 0.39, 95% CI 0.15-0.82).
CONCLUSION
Three distinct phenotypic clusters were identified, each with heterogeneous clinical characteristics and outcomes, underscoring the need for more individualised, phenotype-informed management strategies in this complex patient population.
A. Askarinejad, T. Bucci, Enrico Tartaglia et al.· European journal of internal...· 0 citations
BackgroundNew-onset atrial fibrillation (AF) is a common complication of sepsis, affecting 5-25% of patients, and is associated with increased mortality and ischemic stroke. With limited high-quality evidence, the net clinical benefit of early oral anticoagulant (OAC) initiation in this high-risk setting remains uncertain.MethodsAdults ≥18 hospitalized with sepsis who developed new-onset AF within 3 days were identified from the TriNetX database. Cohort one included patients who received at least three doses of OAC within 3 days after AF onset and was compared to those who did not receive OAC (cohort two). Propensity score matching (1:1; 90 covariates; caliper 0.1) was employed to balance the groups. The primary outcomes assessed were evaluated at 7, 14, and 30 days. Risk ratios and risk differences with 95% confidence intervals were estimated using intention-to-treat analysis.ResultsAmong 136,172 eligible patients, 10,773 were matched per group. Early OAC use was associated with significantly lower mortality at 7, 14, and 30 days (RR 0.19-0.35; all p < 0.001) and reduced ischemic stroke risk across the same intervals (RR 0.74-0.83; p ≤ 0.004). Major bleeding rates were also lower (RR 0.40-0.49; all p < 0.001). MACEs showed a modest reduction at 7 days (RR 0.92; p = 0.001) but not afterward. Thromboembolic events were similar beyond the first week. The need for thrombolytics (RR 0.55-0.59) and anti-hemorrhagic therapy (RR≈0.69) consistently remained lower with OACs (all p < 0.001). Falsification outcomes were neutral, except for a minimal late increase for osteoarthritis at 30 days (RR 1.16; p = 0.03).ConclusionIn sepsis-associated NOAF, early OAC initiation was associated with reduced short-term mortality and ischemic stroke without excess bleeding or thromboembolic risk. The large magnitude of mortality benefit and paradoxical reduction in bleeding likely reflect residual confounding by clinical stability and patient selection. Findings warrant cautious interpretation given the observational design; prospective trials are needed.
A. Qadeer, Michele Fouad, Doaa Bayomi et al.· Journal of Intensive Care Me...· 0 citations
Background No validated and practical tool exists to assess adherence to statins in secondary prevention of cardiovascular disease. Current reference methods for assessing adherence, including plasma drug measurements, are not feasible for routine clinical care or large clinical trials. Objective To develop and internally validate a predictive screening instrument for identifying patients at risk of statin non-adherence. Methods This multicenter cross-sectional study reports the results of the second phase of the GENADHECAR project in four Spanish hospitals. An initial set of 42 adherence-related items was refined and evaluated in a sample of patients with ischemic heart disease. Responses were compared against a pharmacokinetic reference method (plasma statin concentrations) to assess recent medication intake. A multivariate predictive model of non-adherence was then developed, selecting the best predictors and covariates to be included in the final screening instrument. Results A total of 309 patients were included, of whom 49 (15.9%) were classified as non-adherent according to the pharmacokinetic reference method. The final GENADHECAR screening instrument comprised three questionnaire items (use of reminders, forgetfulness, and medication access) and two sociodemographic variables (sex and educational attainment). Internal bootstrap validation yielded an optimism-corrected AUC of 0.694 (95% CI 0.617–0.767), with adequate calibration (Hosmer–Lemeshow p = 0.994). At the selected probability threshold (0.15), sensitivity was 0.73, specificity 0.61, and positive and negative predictive values were 0.26 and 0.92, respectively. Overall, the model showed moderate discrimination and a high capacity to identify patients at low risk of non-adherence. Conclusion To our knowledge, GENADHECAR is the first screening instrument with internal validation to identify statin non-adherence using a pharmacokinetic reference method. It offers a brief and practical approach for identifying patients at risk of non-adherence and may help overcome some limitations of conventional self-report methods in this population. Further external validation is needed before routine clinical implementation.
J. A. Quesada, A. López-Pineda, Rauf Nouni-García et al.· Frontiers in Pharmacology· 0 citations
BACKGROUND
To examine Australian general practitioners' (GPs) perspectives on initiating oral anticoagulation for stroke prevention in patients with atrial fibrillation, and their approaches to monitoring medication adherence and persistence.
METHODS
This qualitative study used semi-structured interviews with Australian GPs recruited from a large survey of anticoagulation practices. Interviews were conducted online, audio-recorded, transcribed verbatim and analysed using thematic analysis with inductive coding. Analysis was undertaken independently by multiple researchers, with consensus reached through team discussion. Interviews continued until thematic saturation was achieved.
RESULTS
Fourteen GPs were interviewed. Initial management of atrial fibrillation and oral anticoagulation initiation varied, with limited access to echocardiography and cardiology services identified as key barriers, along with patient bleeding risk. Assessing and monitoring long-term adherence and persistence remained challenging, particularly among patients with low health literacy, cognitive impairment, polypharmacy and financial constraints. GPs used a range of strategies to monitor and improve adherence and persistence, such as patient education, supplemented by recall systems, multidisciplinary input and pharmacist involvement.
CONCLUSIONS
Australian GPs report multiple challenges in initiating and monitoring anticoagulation for atrial fibrillation. Enabling GPs to confidently start oral anticoagulants without delaying for diagnostic testing/cardiology review, improving access to echocardiography services, and supporting GPs to monitor adherence and persistence may help reduce stroke incidence.
S. Wright, O. Hamed, N. Lowres et al.· Australian Journal of Primar...· 0 citations
Among patients with atrial fibrillation at intermediate risk for stroke, DOAC therapy led to a lower risk of stroke, systemic embolism, major bleeding, or death from cardiovascular causes at 24 months than no anticoagulation.
Daehoon Kim, Young-soo Lee, J. Shim et al.· New England Journal of Medic...· 0 citations
BACKGROUND
Although physical activity (PA) is associated with a reduced risk of stroke and mortality, its impact among individuals with atrial fibrillation (AF) remains insufficiently explored. Therefore, the aim of this study was to examine the impact of PA on stroke and mortality, both overall and with respect to AF diagnosis.
METHODS
We included 87 340 participants, of which 6539 had AF, from 2 Norwegian population-based studies, the Tromsø Study and the HUNT (Trøndelag Health Study). Information about AF, stroke, and death were obtained from national health registries. Participants were classified as inactive (reference) or performing low, moderate, or high PA on the basis of a questionnaire. The data were analyzed using multivariable adjusted flexible parametric survival models.
RESULTS
During a median follow-up of 13.5 years, 3415 strokes and 7833 deaths occurred. The respective stroke risk reduction associated with low, moderate, and high PA was 9% (95% CI, 1%-16%), 19% (95% CI, 11%-27%) and 18% (95% CI, 8%-26%). Mortality was reduced by 11% (95% CI, 7%-14%), 18% (95% CI, 14%-22%), and 22% (95% CI, 18%-27%). Similar benefits were observed for both stroke and mortality when stratifying by presence or absence of AF. Among individuals with AF, an increased life expectancy was observed, with gains of 0.50 (95% CI, 0.22-0.78), 0.66 (95% CI, 0.31-1.01) and 1.15 (95% CI, 0.77-1.53) years, respectively.
CONCLUSIONS
PA was associated with a reduced risk of stroke and mortality, and similar benefits were observed irrespective of AF diagnosis. Our findings suggest that PA may complement current medical treatment strategies in individuals with AF.
K. Johansen, B. Nes, V. Malmo et al.· Journal of the American Hear...· 0 citations
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