Factors Influencing Adherence to Non-Vitamin K Antagonist Oral Anticoagulants in the Early Period After Atrial Fibrillation Catheter Ablation in China
Atrial fibrillation (AF) is a common cardiac arrhythmia associated with an increased risk of thromboembolic events, particularly stroke. Catheter ablation is a widely used treatment for AF, and anticoagulation therapy is routinely prescribed in the weeks following the procedure to mitigate the risk of thromboembolism. Non-vitamin K antagonist oral anticoagulants (NOACs) have emerged as the preferred choice over warfarin due to their superior safety profile, fewer drug interactions, and the absence of the need for regular blood monitoring. However, the lack of routine medical contact with NOACs may lead to poor adherence, which is critical for both efficacy and safety. This study aimed to evaluate adherence to NOACs in the early period after AF catheter ablation in China and identify factors influencing adherence.
Study Design and Methodology
This single-center, retrospective observational study was conducted between September 2018 and January 2019. Patients were included if they were aged 18 years or older, had a definitive diagnosis of AF by electrocardiogram before catheter ablation, underwent AF catheter ablation during the current admission, and were prescribed NOACs at discharge with a requirement to continue treatment for at least three months. Exclusion criteria included patients prescribed NOACs for other indications, those participating in another clinical study, those who suspended NOACs under medical instruction within three months post-ablation, and those unable to understand the research purpose or complete surveys.
Demographic characteristics, medical history, biochemical parameters, and psychological factors such as depression and anxiety were collected within 24 hours of admission. The Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) were used to assess psychological status, with a cutoff score of 50 indicating depression or anxiety. Adherence to NOACs was evaluated using the eight-item Morisky Medication Adherence Scale (MMAS), where a score of 6 to 8 indicated adequate adherence and a score below 6 indicated inadequate adherence. Additionally, the Anticoagulation Knowledge Tool (AKT) questionnaire was administered to assess patients’ understanding of anticoagulation therapy.
Patient Characteristics and Adherence Rates
A total of 373 patients were evaluated, with 41 excluded based on the criteria, resulting in a final sample size of 332. The mean age of the cohort was 59.2 years, with 41.4% being female. Overall, 70.2% of patients exhibited adequate adherence to NOAC therapy. Patients with inadequate adherence were significantly younger (57.4 years vs. 60.1 years) and had higher SDS scores (indicating more severe depression) and lower SAS scores (indicating less anxiety) compared to those with adequate adherence. A significantly higher percentage of AF recurrence was observed in the adequate adherence group (31.3% vs. 16.2%).
Factors Influencing Adherence
In univariate analysis, several factors were significantly associated with adequate adherence, including age over 50 years, employment status, living alone, use of adherence aids such as alarms, pill sorting boxes, and reminders from others, anxiety, and AF recurrence. Multivariate logistic regression analysis revealed that the use of a pill sorting box (odds ratio [OR] = 3.22), being reminded by others (OR = 3.02), anxiety (OR = 2.16), and AF recurrence (OR = 2.16) were independent predictors of adequate adherence.
The use of adherence aids, such as pill sorting boxes and reminders from others, was more common in the adequate adherence group (45.9% vs. 21.2%). Among these methods, being reminded by others was the most frequently used (24.8%), followed by pill sorting boxes and written reminders (8.4%). Only 3.3% of patients used two methods to remind themselves, and these patients exhibited adequate adherence.
Discussion
The study highlights the importance of adherence to NOACs in the early period after AF catheter ablation, as inadequate adherence can compromise both the efficacy and safety of anticoagulation therapy. The findings suggest that adherence aids, such as pill sorting boxes and reminders from others, play a crucial role in improving adherence. These methods have been previously confirmed as effective in enhancing medication adherence in chronic diseases.
The relationship between anxiety and adherence is complex. While some studies have reported that anxiety is associated with better medication adherence, others have found the opposite. In this study, anxiety was positively associated with adherence, likely because patients with AF experience anxiety related to the fear of thromboembolic events, motivating them to adhere to anticoagulation therapy.
The association between AF recurrence and adherence is a novel finding. Patients with AF recurrence were more likely to adhere to NOACs, possibly because they perceived a higher risk of thromboembolic events. In contrast, patients who restored sinus rhythm might assume that the risk of thrombosis is eliminated, leading to discontinuation of anticoagulation therapy. This underscores the need for physicians to educate patients about the importance of continued anticoagulation therapy even after successful ablation.
Limitations
The study has several limitations. First, adherence was self-reported, which may overestimate the actual adherence rate. Second, the factors influencing adherence are complex, and the study may not have accounted for all potential variables. Third, the single-center design may introduce selection bias. Future prospective studies are needed to further explore the relationship between these factors and adherence to NOACs.
Conclusion
Improving adherence to NOACs is critical for the effective management of AF, particularly in the early period after catheter ablation. The use of adherence aids, such as pill sorting boxes and reminders from others, can significantly enhance adherence. Additionally, addressing patients’ anxiety and educating them about the importance of continued anticoagulation therapy, even in the absence of AF recurrence, are essential strategies for improving adherence. Greater attention to these factors can help optimize the management of AF and reduce the risk of thromboembolic events.
doi.org/10.1097/CM9.0000000000001000
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