Non-adherence to recommended secondary preventive anticoagulation in
stroke patients with
atrial fibrillation (AF) is a common phenomenon although the introduction of direct oral
anticoagulants (DOACs) has simplified anticoagulation management for physicians as well as for patients.
METHODS: We examined the adherence of secondary preventive anticoagulation in AF patients after re-integration in their social environment 6 to 12 weeks after
stroke unit and rehabilitation clinic treatment and analyzed for predictors for adherence and non-adherence. We conducted a telephone survey in consecutive patients treated between January 2013 and December 2021 at our institutional
stroke unit with an acute cerebrovascular ischemic event and we analyzed discharge letters of rehabilitation clinics of those patients not anticoagulated at follow-up. All patients had known or newly diagnosed AF and in all we had recommended secondary preventive anticoagulation.
RESULTS: Follow-up information about
anticoagulant intake could be obtained in 1348 of 1685 patients (80.0%) treated within the study period. Anticoagulation rate was 91.5% with 83.6% of patients receiving DOACs and 7.9% receiving
vitamin K antagonists (VKAs). Adherence to recommended anticoagulation was associated with intake of the recommended
anticoagulant already at discharge (adjusted OR, 18.357; CI, 9.637 to 34.969), recommendation of a specific DOAC and dose (in contrast to "DOAC" as drug category) (adjusted OR, 2.971; CI, 1.173 to 7.255), a lower modified Rankin Scale at discharge (per point; adjusted OR, 0.813; CI, 0.663 to 0.996), younger age (per year; adjusted odds ratio [OR], 0.951; confidence interval [CI], 0.926 to 0.976), and the absence of
peripheral vascular disease (adjusted OR, 0.359; CI, 0.173 to 0.746). In patients already anticoagulated at discharge adherence was 98.5%, irrespective of a patient's age, functional deficit at discharge, and
peripheral vascular disease. Avoidable obstacles for non-adherence in patients not on
anticoagulants at
stroke unit discharge were (1) non-implementation of recommended anticoagulation by rehabilitation physicians predominantly in patients with moderate-severe or severe
stroke disability (2.1%), (2) delegation of anticoagulation start from rehabilitation physicians to general practitioners/resident radiologists (1.3%), and (3) rejection of recommended anticoagulation because of patients' severe
stroke disability (0.5%). Non-avoidable obstacles were
contraindications to anticoagulation (2.1%) and patients' refusal (0.7%).
CONCLUSIONS: Commencing drug administration already during
stroke unit hospitalization and providing an explanation for the selection of the recommended
anticoagulant in discharge letters ensures high adherence at patients' re-integration in their social environment after
acute stroke treatment. If drug administration cannot be commenced before discharge, education of rehabilitation physicians by
stroke physicians and the involvement of
stroke physicians into the post-
stroke decision process might hinder avoidable obstacles.