From prescription to bleeding complication: challenges surrounding daily anticoagulant care

Abstract

This thesis explores key challenges in daily clinical anticoagulant care: inappropriate prescribing, suboptimal adherence, and bleeding complications.

The prevalence, underlying rationales, predictors, and potential clinical consequences of inappropriate inpatient prescribing of direct oral anticoagulants (DOACs) were examined. Dose reduction criteria from various guidelines were reviewed, illustrating the complexity of achieving appropriate dosing in practice.

Adherence is critical to treatment success. We assessed adherence to oral anticoagulation in patients with atrial fibrillation (AF), identified predictors for non-adherence, and examined patients’ beliefs about anticoagulants and their experiences with side effects. Both pharmacy-based and self-reported adherence measures were evaluated to capture different dimensions of treatment behaviour.

Bleeding remains the principal limitation of anticoagulant therapy. We investigated the use, effectiveness, and safety of idarucizumab, a reversal agent for dabigatran. Moreover, the predictive performance of bleeding risk scores was evaluated in patients with AF and in the high-risk population of left ventricular assist device (LVAD) recipients. Together, these studies provide an integrated overview of the multifaceted challenges in anticoagulant management, offering insights into prescribing practices, patient engagement, and bleeding risk assessment in routine care.