When Every Dose Counts: Multi-Country Real-World Insights on Stroke Risk

Atrial fibrillation (AF) is a common heart rhythm disorder that increases the risk of ischemic stroke five-fold. Direct oral anticoagulants (DOACs) are now widely used to reduce this risk, but their protective effect depends critically on continuous use. Unlike warfarin, DOACs lose their anticoagulation effect rapidly when doses are missed—a phenomenon known as the rebound effect.

Despite strong evidence from randomized trials, little was known about how real-world adherence and persistence influence stroke risk across different healthcare systems.

Research challenge

The challenge was twofold:

• Measure adherence and persistence accurately in real-world settings without relying on patient recall—avoiding social desirability bias
• Compare across multiple countries with differing healthcare structures, prescribing patterns, and patient demographics, while ensuring results were robust and generalizable