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Published on: February 28, 2012
Oral anticoagulant discontinuation in patients with nonvalvular atrial fibrillation
Sumesh Kachroo, Melissa Hamilton, Xianchen Liu
1University of Utah College of Pharmacy, L.S. Skaggs Pharmacy Institute, 30 South 2000 East, Rm 4962, Salt Lake City, UT 84112.
Insights
Discontinuation of oral anticoagulants (OACs) is common in nonvalvular atrial fibrillation (NVAF) patients. Direct oral anticoagulants (DOACs) and certain comorbidities reduce discontinuation risk, while prior bleeding increases it.
Area of Science:
- Pharmacology and Therapeutics
- Cardiology
- Health Services Research
Background:
- Oral anticoagulants (OACs) are crucial for preventing stroke in nonvalvular atrial fibrillation (NVAF) patients.
- Discontinuation of OAC therapy can lead to increased risk of thromboembolic events.
- Identifying factors associated with OAC discontinuation is essential for optimizing patient management.
Purpose of the Study:
- To identify patient and treatment-related factors associated with all-cause discontinuation of OACs in NVAF patients.
- To compare discontinuation rates between warfarin and direct oral anticoagulants (DOACs).
Main Methods:
- Retrospective cohort study utilizing the MarketScan claims database (October 2009 - July 2012).
- Inclusion criteria: adult NVAF patients newly initiating OACs with at least 6 months continuous enrollment post-initiation.
- Multivariable Cox proportional hazards regression analysis to determine factors associated with discontinuation.
Main Results:
- Overall, 47.3% of 12,129 eligible NVAF patients discontinued OACs.
- Patients on DOACs (HR, 0.91) compared to warfarin had a lower risk of discontinuation.
- Factors associated with lower discontinuation risk included older age, diabetes, prior stroke/TIA, pulmonary embolism, and congestive heart failure.
- Prior bleeding events were associated with a higher risk of discontinuation (HR, 1.20).
Conclusions:
- The risk of OAC discontinuation in NVAF patients is substantial.
- DOACs and certain comorbidities are associated with a reduced risk of OAC discontinuation.
- Prior bleeding history is a significant predictor of increased OAC discontinuation.
Objectives:
To identify factors associated with all-cause discontinuation (patient discontinued on their own or physician discontinuation) of oral anticoagulants (OACs) among nonvalvular atrial fibrillation (NVAF) patients.
Study Design:
Retrospective cohort study.
Methods:
We analyzed the MarketScan claims database from October 2009 to July 2012. Adult patients were eligible if they newly initiated an OAC in the study period, had an atrial fibrillation diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification code 427.31 or 472.32), and had at least 6 months of continuous enrollment after OAC initiation. Multivariable Cox proportional hazards regression was used to assess factors associated with discontinuation. Adjusted hazard ratios (HRs) and 95% CIs were reported.
Results:
Among 12,129 eligible patients, 8143 (67.1%) initiated warfarin and 3986 (32.9%) initiated direct oral anticoagulants (DOACs). Overall, 47.3% of patients independently discontinued during follow-up (mean number of days of follow-up = 416.6 [SD ± 141.7]) with mean time to discontinuation of 120 days (SD ± 114.7). Patients significantly less likely to discontinue included those taking DOACs versus warfarin (HR, 0.91; 95% CI, 0.86-0.97), older patients (≥65 years vs 18 to 34 years) (HR, 0.32; 95% CI, 0.24-0.43), those with diabetes (HR, 0.84; 95% CI, 0.77-0.90), those with prior stroke/transient ischemic attack (HR, 0.65; 95% CI, 0.56-0.75), those with prior pulmonary embolism (HR, 0.71; 95% CI, 0.58-0.88), and those with congestive heart failure (HR, 0.80; 95% CI, 0.74-0.87). Patients with prior bleeding events were significantly more likely to independently discontinue (HR, 1.20; 95% CI, 1.08-1.34).
Conclusions:
The risk of independent discontinuation of OAC treatment among NVAF patients was high. Patients on DOACs compared with warfarin and those with several comorbid conditions had significantly lower risk of discontinuation, while those with prior bleeding were more likely to discontinue.
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