title: Reasons underlying non-adherence to and discontinuation of anticoagulation in secondary stroke prevention among patients with atrial fibrillation.
abstract: BACKGROUND
  Although long-term oral anticoagulation (OAC) with vitamin K antagonists for secondary stroke prevention in atrial fibrillation (AF) is highly effective, it is frequently not started or discontinued in clinical practice. We analyzed the reasons for stroke patients' and physician's nonadherence.
  
  
  METHODS
  In this prospective, observational, single-center cohort study, consecutive patients diagnosed with acute ischemic stroke or transient ischemic attack (TIA) and AF presenting during a nine-month period were included. Adherence to OAC was evaluated at 15 ± 1 months after the event using a semi-structured telephone interview. In patients without anticoagulation, the primary care physician (PCP) was contacted to explore the reason. Associations between nonadherence to OAC therapy at follow-up and potential predictors were assessed by logistic regression analysis.
  
  
  RESULTS
  Of the 1,049 presenting stroke/TIA patients, 139 with a first (n = 101) or a continued recommendation (n = 38) of OAC were analyzed. After 15 months, 54 patients (39% of 85 patients with OAC at follow-up) were nonadherent. The main reasons for patients' nonadherence were fear of side effects (e.g., bleeding) and inconvenience of regular international normalized ratio measurements. In two-thirds (36/54) of cases, OAC was not prescribed by the PCP; the most important reasons were a putative high risk of falling and dementia. Risk factors for nonadherence were dementia, living in a nursing home, and the noninitiation of OAC during in-hospital stay. Treatment was temporarily discontinued in 21 (25%) of patients on OAC at follow-up.
  
  
  CONCLUSIONS
  Nonadherence to OAC in stroke patients results from fear of potential complications or inconvenience and physicians' concerns regarding functional status. OAC should be initiated wherever possible during the in-hospital stay.
authors: Department of Neurology, University of Heidelberg, Heidelberg, Germany.
authors: Christoph
authors: C
authors: Gumbinger
authors: Timo
authors: T
authors: Holstein
authors: Christian
authors: C
authors: Stock
authors: Timolaos
authors: T
authors: Rizos
authors: Solveig
authors: S
authors: Horstmann
authors: Roland
authors: R
authors: Veltkamp
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D001281:Atrial Fibrillation / Q000150:complications; D015331:Cohort Studies; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D010820:Physicians; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012307:Risk Factors; D055502:Secondary Prevention / Q000379:methods*; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D016903:Drug Monitoring
chemical_list: D000925:Anticoagulants