Hello, I’m Dr. Sam Goldhaber, President of NATF, and I’m here on Clot Chronicles to discuss a recent study of more than 20,000 patients with atrial fibrillation (Afib). 

This study looked at the consequences of discontinuing anticoagulation. For many patients with Afib, anticoagulation is the cornerstone of management to prevent stroke. What is less well appreciated is that patients with Afib are also highly susceptible to myocardial infarction (MI), heart failure (HF), and all-cause mortality (ACM). Stroke gets most of the spotlight. 

And I think there’s a general feeling that if one has to stop anticoagulation for a couple of weeks for whatever reason, or if one forgets and doesn’t get the prescription renewed, that everything is going to be okay – not a big deal. But this paper from the GARFIELD-AF trial says otherwise. GARFIELD-AF was a 10-year study, the largest study of its type in Afib, that randomized more than 50,000 patients with Afib and followed them from the time they entered the study—and 5 separate cohorts entered—until the end of a 10-year period. This particular study within GARFIELD-AF looks at the most recent cohorts that were entered and assessed what happens with discontinuing anticoagulation during this period of time to the Afib patient. 

So, there are several important lessons from this. First, most of the discontinuation—between 35 and 40% of the discontinuation—occurs within 4 months of the initial prescription of an anticoagulant. For us clinicians, that means that we have to be particularly vigilant about adherence to anticoagulation during this fragile period of time. And I think it’s not just physicians, it’s family members, other healthcare providers, and friends. 

Second, this study—a multinational study from about 30 countries—showed that the United States had next to the highest rate of discontinuation of any other country. In the United States, the discontinuation rate was around 15% during this 2-year period of follow-up. 

Now, the analysis of the consequences of anticoagulation discontinuation were done in 2 separate timepoints – discontinuation for a 7-day period and discontinuation for a 30-day period. And if you discontinued anticoagulation for 30 or more days, you had a considerably higher rate of MI, stroke, and death. If you discontinued anticoagulation for up to 7 days, you had almost the same increased likelihood of MI, stroke, or death, and this is the real surprise—or the kicker—in the study. The study is telling us don’t make light of a 1-week discontinuation. Try to keep it under 7 days if possible. 

And finally, in this study, it didn’t matter whether the patient was being anticoagulated with warfarin or with a DOAC – the results were, essentially, the same in terms of the consequences of stopping the anticoagulation. So, we know as healthcare providers that adherence to the medical therapy we prescribe, in general, is a big challenge. And this paper from the GARFIELD-AF registry published in the Journal of Thrombosis and Haemostasis is telling us keep an eye on patients, especially during the first 4 months after the anticoagulation is prescribed. And try, at all costs, to keep any period of discontinuing anticoagulation to less than 7 days. 

This is Dr. Sam Goldhaber signing off for Clot Chronicles.