Your older patients with atrial fibrillation: Are you missing the broader picture?
Archie is 70 years old and has recently retired after working for 33 years as a civil engineer. For several years he has been eagerly looking forward to spending more time with his four young grandchildren. He has a history of hypertension but is otherwise well. Following several recent episodes of feeling faint and dizzy, he was diagnosed with non-valvular atrial fibrillation (NVAF). After discussion with his doctor, the decision was made to start anticoagulation.
At the age of 70, it is likely that Archie will be on anticoagulation for many years to come; although he is not in a vulnerable population now, he may well be in the future. How would you treat Archie to ensure that he receives the best possible protection against the complications of atrial fibrillation (AF)?
Chronic AF may be the first sign of worsening disease status for potentially vulnerable patients
Patients with AF frequently suffer from co-morbid diseases, which can complicate treatment and worsen prognosis. Several often-encountered challenges facing patients with AF are: diabetes (found in around 22% of patients with AF), renal impairment (found in around 10% of patients with AF) and cardiovascular disease (of which coronary artery disease alone is found in around 20% of patients with AF).1 All of these co-morbidities can influence the likelihood of stroke or alter bleeding risk.2-4
Co-morbidities are frequently encountered in patients with AF1
AF, atrial fibrillation
Opting for the most appropriate anticoagulant for a patient with AF can provide the best chance of protection from the potentially life-threatening or debilitating consequences of stroke.5
Rivaroxaban has been extensively studied in the patients you worry about the most
It is important that clinical trials are conducted in patient populations that are representative of those who will ultimately be prescribed the treatment. The ROCKET AF trial studied rivaroxaban in vulnerable patients with AF, its population had the highest mean CHADS2 score of the phase III non-vitamin K antagonist oral anticoagulant (NOAC) studies.6 Around 40% of patients in ROCKET AF had diabetes, 21% had moderate renal impairment, 63% had heart failure and 55% had experienced a prior stroke or a transient ischaemic attack (TIA).6,7 Of the phase III NOAC trials, this was the greatest proportion of patients with these conditions, with results that consistently demonstrated a reliable treatment effect.7-11
ROCKET AF had the most vulnerable patient population of the phase III NOAC studies8-11
CHADS2, Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, Stroke or transient ischaemic attack (2 points); NOAC, non-vitamin K oral anticoagulant. The results are not intended for direct comparison.
Extensive data can help to build confidence in a treatment. In addition to the vulnerable patient population assessed in ROCKET AF, a broad range of data have been generated from studies of patients on rivaroxaban in the real-world setting. For example, RIVA-DM is a large, retrospective electronic health records analysis study that has shown that patients in the real-world setting with diabetes and AF experience a similar benefit from rivaroxaban compared with warfarin as seen in the ROCKET AF study.6,12 RIVA-DM also showed that there were lower rates of cardiovascular death in this high-risk group than with warfarin, which was consistent with a subanalysis of ROCKET AF.13,14 The RELOAD and ANTENNA studies have also provided reassuring data. The RELOAD study demonstrated reduced incidence of stroke and intracranial haemorrhage in patients with impaired renal function versus phenprocoumon.15 Results from ANTENNA showed that patients with preserved renal function experienced a safety profile consistent with phase III clinical trial findings, and also showed a benefit in terms of worsening kidney function versus warfarin.16
For many patients with AF, there is a breadth of data available for rivaroxaban that can provide reassurance that it has been thoroughly tested in patients just like themselves.
Treatment adherence and persistence are critical for vulnerable patients on anticoagulation
Modern AF management strategies, like those encouraged by the European Society of Cardiology (ESC), emphasize integrated, patient-centred management, and can provide a way to improve adherence.17 Placing your patient at the centre of their management means considering all options for medication, given both their current health status and an awareness of any possible complicating factors that may develop over time.
For vulnerable patients at high risk of stroke, it is not enough to just prescribe an anticoagulant, the patient must stick to their treatment. Around one-third of patients are not adherent to stroke prevention therapy, and those patients have twice the risk of stroke compared with patients who adhere to their treatment.18
The factors that influence medication adherence can be broken down into patient factors, physician factors and healthcare system factors.17 Physicians influence adherence through effective reduction of polypharmacy and by working with patients to improve their understanding of their condition and treatment.17
Factors influencing adherence can be divided into three groups17
Dr Yassir Javaid highlighted how important it was to encourage adherence to anticoagulation therapy: “It’s a really good opportunity to reinforce that significant increase in stroke risk, and the tremendous importance and opportunity of reducing that risk with compliance with a good quality anticoagulation therapy”.
Promoting a patient’s understanding of their condition is an important way to optimize their adherence and subsequent protection from anticoagulation.17 In addition, studies have found that reducing pill burden increases the likelihood of adherence to treatment.19 Selecting a treatment regimen with only one daily dose, such as rivaroxaban, may provide a solution to further optimize adherence.
When prescribing anticoagulation, ensure you are thinking of your patient’s past, present, and potential future
For patients who are likely to be on anticoagulation in the long-term, such as Archie, the decision of which is the most appropriate treatment selection should be multifactorial and should consider their current situation while looking towards the longer-term challenges of increasing age and the likelihood of developing co-morbidities. Putting patients at the centre of the decision-making process will provide them with the best opportunity to benefit from stable, long-term continuous treatment, regardless of any future complications.
References
- Bassand JP, Accetta G, Al Mahmeed W et al. Risk factors for death, stroke, and bleeding in 28,628 patients from the GARFIELD-AF registry: rationale for comprehensive management of atrial fibrillation. PLoS One 2018;13:e0191592. Return to content
- Steffel J, Collins R, Antz M et al. 2021 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Europace 2021;23:1612–1676. Return to content
- Kreutz R, Camm AJ, Rossing P. Concomitant diabetes with atrial fibrillation and anticoagulation management considerations. Eur Heart J Suppl 2020;22:O78–O86. Return to content
- Michniewicz E, Mlodawska E, Lopatowska P et al. Patients with atrial fibrillation and coronary artery disease - double trouble. Adv Med Sci 2018;63:30–35. Return to content
- Baumann M, Le Bihan E, Chau K, Chau N. Associations between quality of life and socioeconomic factors, functional impairments and dissatisfaction with received information and home-care services among survivors living at home two years after stroke onset. BMC Neurol 2014;14:92. Return to content
- Patel MR, Mahaffey KW, Garg J et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med 2011;365:883–891. Return to content
- Fox KAA, Piccini JP, Wojdyla D et al. Prevention of stroke and systemic embolism with rivaroxaban compared with warfarin in patients with non-valvular atrial fibrillation and moderate renal impairment. Eur Heart J 2011;32:2387–2394. Return to content
- Halperin JL, Hankey GJ, Wojdyla DM et al. Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF). Circulation 2014;130:138–146. Return to content
- Halvorsen S, Atar D, Yang H et al. Efficacy and safety of apixaban compared with warfarin according to age for stroke prevention in atrial fibrillation: observations from the ARISTOTLE trial. Eur Heart J 2014;35:1864–1872. Return to content
- Lauw MN, Eikelboom JW, Coppens M et al. Effects of dabigatran according to age in atrial fibrillation. Heart 2017;103:1015–1023. Return to content
- Kato ET, Giugliano RP, Ruff CT et al. Efficacy and safety of edoxaban in elderly patients with atrial fibrillation in the ENGAGE AF-TIMI 48 trial. J Am Heart Assoc 2016;5:e003432. Return to content
- Coleman C, Brescia C, Vardar B et al. Thromboembolism, bleeding, and vascular death among older and younger nonvalvular atrial fibrillation patients with type 2 diabetes receiving rivaroxaban or warfarin. American Society of Hematology Annual Meeting. Atlanta, USA, 11–14 December 2021. Poster & Abstract 3234. Return to content
- Coleman CI, Costa OS, Brescia CW et al. Thromboembolism, bleeding and vascular death in nonvalvular atrial fibrillation patients with type 2 diabetes receiving rivaroxaban or warfarin. Cardiovascular diabetology 2021;20:52. Return to content
- Bansilal S, Bloomgarden Z, Halperin JL et al. Efficacy and safety of rivaroxaban in patients with diabetes and nonvalvular atrial fibrillation: the Rivaroxaban Once-daily, Oral, Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF Trial). Am Heart J 2015;170:675–682. Return to content
- Bonnemeier H, Huelsebeck M, Kloss S. Comparative effectiveness of rivaroxaban versus a vitamin K antagonist in patients with renal impairment treated for non-valvular atrial fibrillation in Germany - a retrospective cohort study. Int J Cardiol Heart Vasc 2019;23:100367. Return to content
- González-Pérez A, Balabanova Y, Sáez ME et al. Renal decline in patients with atrial fibrillation treated with rivaroxaban or warfarin. European Society of Cardiology Congress.Virtual, 27–30 August 2021. Poster Available at: https://esc2021-abstract.medicalcongress.online/mediatheque/media.aspx?channel=103467&mediaId=104597 [accessed 5 November 2021]. González-Pérez A, Balabanova Y, Sáez ME et al. Renal decline in patients with atrial fibrillation treated with rivaroxaban or warfarin. European Society of Cardiology Congress.Virtual, 27–30 August 2021. Poster Available at: https://esc2021-abstract.medicalcongress.online/mediatheque/media.aspx?channel=103467&mediaId=104597 [accessed 5 November 2021]. Return to content
- Hindricks G, Potpara T, Dagres N et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2021;42:373–498. Return to content
- Salmasi S, Loewen PS, Tandun R et al. Adherence to oral anticoagulants among patients with atrial fibrillation: a systematic review and meta-analysis of observational studies. BMJ Open 2020;10:e034778. Return to content
- Kini V, Ho PM. Interventions to improve medication adherence: A review. JAMA 2018;320:2461–2473. Return to content
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