National trends of use of oral anticoagulants and severities of stroke among patients with atrial fibrillation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
T.F Chao ◽  
J.N Liao ◽  
G.Y.H Lip ◽  
S.A Chen
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Prevention ◽  
Oral Anticoagulants ◽  
Temporal Trends ◽  
Daily Practice ◽  
Severity Index ◽  
Stroke Severity ◽  
Research Database ◽  
Prescription Rates

Abstract Background Underuse of oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation (AF) is a common issue in the daily practice. The introduction of non-vitamin K antagonist OACs (NOACs) has changed the landscape of stroke prevention in AF. The goal of the present study was to investigate the trends of use of OACs and severities of stroke among AF patients using a nationwide AF database. Methods The present study used the Taiwan Nationwide Health Insurance Research Database (NHIRD). From year 2002 to 2015, a total of 66,331 AF patients aged >20 years who experienced ischemic stroke were identified from 447,259 AF patients. The temporal trends of use of OACs (either warfarin or NOACs) and the severities of stroke were analyzed. The estimated National Institutes of Health Stroke Scale (eNIHSS) calculated by 7-item NHIRD based stroke severity index, which has been validated before, was used to represent the stroke severities. Results The percentages of AF patients who were already anticoagulated when stroke occurred significantly increased from 20.3% in year 2002 to 40.5% in year 2015 (Figure A). The increment was more obvious in the era of NOACs (after year 2012 in Taiwan). In year 2015, NOACs accounts for around 69.6% of prescriptions of OACs. The mean eNIHSS gradually decreased from 17.3 (year 2002) to 14.3 (year 2015) (Figure B). Conclusions In the era of NOACs, the prescription rates of OACs significantly increased among AF patients who experienced ischemic stroke, temporally associated with a decrease in the stroke severity. Funding Acknowledgement Type of funding source: None

New Avenues for Optimal Treatment of Atrial Fibrillation and Stroke Prevention

Stroke ◽  
2021 ◽  
Author(s):  
Gian Marco De Marchis ◽  
Luciano A. Sposato ◽  
Michael Kühne ◽  
Tolga D. Dittrich ◽  
Leo H. Bonati ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Interdisciplinary Approach ◽  
Left Atrial Appendage Occlusion ◽  
High Risk Populations

One in 3 individuals free of atrial fibrillation (AF) at index age 55 years is estimated to develop AF later in life. AF increases not only the risk of ischemic stroke but also of dementia, even in stroke-free patients. In this review, we address recent advances in the heart-brain interaction with focus on AF. Issues discussed are (1) the timing of direct oral anticoagulants start following an ischemic stroke; (2) the comparison of direct oral anticoagulants versus vitamin K antagonists in early secondary stroke prevention; (3) harms of bridging with heparin before direct oral anticoagulants; (4) importance of appropriate direct oral anticoagulants dosing; (5) screening for AF in high-risk populations, including the role of wearables; (6) left atrial appendage occlusion as an alternative to oral anticoagulation; (7) the role of early rhythm-control therapy; (8) effect of lifestyle interventions on AF; (9) AF as a risk factor for dementia. An interdisciplinary approach seems appropriate to address the complex challenges posed by AF.

P4787Use of direct oral anticoagulants in patients with atrial fibrillation having a history of intracranial hemorrhage

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T F Chao ◽  
S A Chen
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Research Database ◽  
Bleeding Events ◽  
Risk Of Mortality ◽  
Taiwan National Health Insurance ◽  
History Of

Abstract Background Patients with atrial fibrillation (AF) having a history of intracranial hemorrhage (ICH) were excluded from the pivotal randomized trials comparing direct oral anticoagulants (DOACs) and warfarin. We aimed to compare the effectiveness and safety of DOACs and warfarin among AF patients having a history of ICH. Method A total of 4,540 AF patients having a CHA2DS2-VASc score ≥1 for males and ≥2 for females who had a history of ICH and received oral anticoagulants (DOACs in 3,493 and warfarin in 1,047) were identified from the Taiwan National Health Insurance Research Database. A propensity matching analysis was performed to balance the baseline differences, and 973 patients were finally identified in each groups. Results The risk of ischemic stroke did not differ significantly between warfarin and DOACs (4.41%/yr vs 4.87%/yr; HR 0.985, p=0.927). The risks of bleeding events were lower with DOACs compared to warfarin with a HR (95% CI) of 0.752 (0.573–0.986, p=0.040) for major bleeding and 0.614 (0.379–0.995, p 0.048) for ICH. The risk of mortality was also lower in patients treated with DOACs (HR = 0.539; 95% CI = 0.453–0.642, p<0.001). The cumulative incidence curves of each events for 2 groups are shown in Figure. Conclusion Compared to warfarin, DOACs were associated with a similar risk of ischemic stroke and better safety profiles among AF patient with a history of ICH.

scholarly journals Ischemic Stroke With Atrial Fibrillation

Stroke ◽  
2021 ◽  
Author(s):  
Amélie Gabet ◽  
Charles Guenancia ◽  
Gauthier Duloquin ◽  
Valérie Olié ◽  
Yannick Béjot
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Oral Anticoagulants ◽  
Temporal Trends ◽  
Population Based ◽  
Newly Diagnosed ◽  
Medical File ◽  
Oral Anticoagulant Treatment ◽  
Stroke Registry

Background and Purpose: Because of the aging population, an increase in the prevalence of atrial fibrillation (AF) is currently observed, thus leading to a rise in AF-related ischemic stroke (IS). We analyzed the current prevalence of AF among patients with IS, their characteristics, and temporal trends from 2006 to 2017 in the population-based Dijon Stroke Registry. Methods: We used data from the Dijon Stroke Registry, an ongoing population-based study that records all cases of acute stroke among residents of the city of Dijon. All patients with IS between 2006 and 2017 were included. Previous AF was defined if it was mentioned in the medical file before stroke and newly diagnosed AF if it was diagnosed during the diagnostic workup of patients with acute stroke. Results: During the period 2014 to 2017, among the 796 patients with IS recorded in the Dijon Stroke Registry, 239 (30.0%) had AF, of whom 79 (9.9% of total patients with IS) had newly diagnosed AF, and 98 (12.3%) had previous AF treated with oral anticoagulants. Patients with IS with AF had more disabilities and a higher initial severity according to the National Institutes of Health Stroke Scale compared with those without AF. The age-adjusted prevalence of AF in patients with IS increased between 2006 and 2017 (+9% per time period), with an important increase in men aged 65 to 74 years (+81%) and women aged ≥85 years (+24%), and a significant decrease in women aged 65 to 74 years (−39%). The use of oral anticoagulant treatment in previous AF patients increased between 2006 and 2009 and 2014 and 2017 (29.3% to 61.3%, P <0.0001). However, 37.5% of patients with previous AF and CHADS 2 score ≥2 were not treated with OAC. Conclusions: The increase in AF prevalence in patients with IS could be related to a better diagnosis of this condition. The underuse of oral anticoagulation treatment was still observed.

P4771Novel oral anticoagulants plus antiplatelet therapy vs. vitamin K antagonists plus antiplatelet therapy in atrial fibrillation patients who underwent percutaneous coronary intervention:a meta-analysis

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
L G Almelor-Sembrana ◽  
M A Gloria ◽  
M M Alejandria
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Stent Thrombosis ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Percutaneous Coronary ◽  
Clinically Significant

Abstract Background Atrial fibrillation (AF) patients who undergo percutaneous coronary intervention (PCI) for coronary artery disease are a therapeutic challenge. Current evidence specifies the need for antiplatelet therapy (APT) to prevent stent thrombosis, but this alone is inadequate for stroke prevention. Oral anticoagulation (OAC) is necessary for stroke prevention in AF patients, but this alone is insufficient to prevent stent thrombosis. The concurrent administration of APT with vitamin K antagonists (VKAs) is associated with increased bleeding. At present, there is limited data on the effectiveness and safety benefit of novel oral anticoagulants (NOACs) plus APT in the prevention of ischemic stroke and stent thrombosis among AF patients who undergo PCI. Purpose This review compared NOACs plus APT versus VKAs plus APT in preventing mortality, myocardial infarction (MI), ischemic stroke, and clinically significant bleeding among AF patients who underwent PCI. Methods The electronic databases MEDLINE and CENTRAL and the clinical trial databases ClinicalTrials.gov and ISRCTN registry were systematically searched in February 2019 for all published and unpublished randomized controlled trials (RCTs) comparing NOACs plus APT versus VKAs plus APT in AF patients who underwent PCI. Manual searching was done by reviewing the references of available studies. There were no language restrictions. Screening and data extraction were done using standardized forms, and evaluated independently by the authors using the Cochrane Collaboration's tool for assessing risk of bias. Disagreements were resolved by discussion. Statistical analysis used RevMan 5.3 (The Nordic Cochrane Centre, 2014). Summary effects were expressed by risk ratios and 95% confidence intervals. Heterogeneity was assessed by visual inspection of forest plots and by I2 statistic ≥40%. Results The search identified 63 records of which 60 studies were excluded (55 studies did not fulfill inclusion criteria, 1 RCT is awaiting additional data, and 4 RCTs are currently ongoing). Three studies were included in the final qualitative and quantitative synthesis. All included RCTs compared a NOAC plus single APT versus warfarin plus dual APT (aspirin and a P2Y12 inhibitor). Based on two moderate quality RCTs with a combined population of 4,820 patients, we found that NOACs plus single APT are not statistically different from warfarin plus dual APT in preventing MI, stroke, or all-cause mortality (RR 1.00, 95% CI 0.75–1.34; I2=48%) in AF patients who undergo PCI. Based on two high quality RCTs with a combined population of 4,824 patients, NOACs plus single APT are definitely superior to warfarin plus dual APT in reducing clinically significant bleeding (RR 0.66, 95% CI 0.59–0.74; I2=0%). Figures Conclusion In AF patients who undergo PCI, NOACs plus single APT are as effective as warfarin plus dual APT in preventing major adverse cardiac events, but with significantly less bleeding risk.

Temporal Trends in Pharmacological Stroke Prevention in Patients with Acute Ischemic Stroke and Known Atrial Fibrillation

2020 ◽  
Vol 29 (12) ◽  
pp. 105266
Author(s):  
Simon Hellwig ◽  
Ulrike Grittner ◽  
Juliane Herm ◽  
Rudi Ruschmann ◽  
Maria Konieczny ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Prevention ◽  
Temporal Trends

P4793Comparing the effectiveness and safety of non-vitamin K antagonist oral anticoagulants and warfarin in the elderly Asian patients with atrial fibrillation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T F Chao ◽  
J N Liao ◽  
G Y H Lip ◽  
S A Chen
Keyword(s):  
Atrial Fibrillation ◽  
Adverse Events ◽  
Elderly Patients ◽  
Vitamin K ◽  
Stroke Prevention ◽  
Lower Risk ◽  
Oral Anticoagulants ◽  
The Elderly ◽  
Vitamin K Antagonist ◽  
Research Database

Abstract Background Stroke prevention in elderly patients with atrial fibrillation (AF) can be challenging. Comparisons of non-vitamin K antagonist oral anticoagulants (NOACs) and warfarin in the elderly, at different age strata (age 65–74, 75–89, ≥90) in the daily practice have not been well described, particularly in Asians. We aimed to assess the clinical outcomes of NOACs compared warfarin for stroke prevention in elderly patients with AF. Methods A total of 64,169 AF patients aged ≥65 years receiving NOACs or warfarin prescription were identified from the Taiwan National Health Insurance Research Database. The risks of adverse events were compared between NOACs and warfarin in all patients age ≥65 and specifically, with different age strata; that is 65–74 years, 75–89 years and >90 years. Results Overall NOACs were associated with a significantly lower risk of ischemic stroke (adjusted hazard ratio [aHR] 0.869, 95% confidence interval [CI] 0.812–0.931), ICH (aHR 0.524, 95% CI 0.456–0.601), major bleeding (aHR 0,824, 95% CI 0.776–0.875), mortality (aHR 0.511, 95% CI 0.491–0.532) and composite adverse events (aHR 0.646, 95% CI 0.625–0.667) compared to warfarin. There was heterogeneity in treatment effect for NOACs versus warfarin in different age strata, but the results still favored NOACs even among the very elderly (>90 years). The absolute risk difference and reductions in ICH and composite adverse events with NOAC use were even greater among the elderly compared to warfarin (Figure). Conclusions Compared to warfarin, NOACs were associated with a significantly lower risk of adverse events, with heterogeneity in treatment effects among different age strata. Overall, the clear safety signal in favor of NOACs over warfarin was evident irrespective of age strata, being most marked in the most elderly.

P4773Oral anticoagulants in patients with atrial fibrillation having an intermediate risk of ischemic stroke but a high risk of bleeding

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T F Chao ◽  
S A Chen
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
High Risk ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Research Database ◽  
Intermediate Risk ◽  
Risk Of Bleeding ◽  
Clinical Benefits ◽  
Taiwan National Health Insurance

Abstract Background The use of oral anticoagulants (OACs) for patients with atrial fibrillation (AF) for stroke prevention should be balanced between the reduction on stroke risk and the increase in bleeding. Our aim was to investigate net clinical benefits of OACs among AF patients with a CHA2DS2-VASc score of 1 (males) or 2 (females) who had a HAS-BLED score ≥3. Method A total of 404,949 newly diagnosed AF patients were identified from the Taiwan National Health Insurance Research Database. The stroke risk was assessed using the CHA2DS2-VASc score and patients were classified as low (score 0 for males, 1 for females), intermediate (1 for males and 2 for females) and high risk (≥2 for males and ≥3 for females). A high risk of bleeding was defined as a HAS-BLED score ≥3. Results The CHA2DS2-VASc and HAS-BLED scores were significantly correlated (r=0.70). Around 72.7% of patients with a high-risk of stroke had a HAS-BLED score ≥3 (Figure A). Among patients with a CHA2DS2-VASc score of 1 (males) or 2 (females) who had a HAS-BLED score ≥3, the use of OACs was associated with a lower risk of adverse events (ischemic stroke, intra-cranial hemorrhage or mortality) with an adjusted hazard ratio of 0.781 (p=0.037) (Figure B). Conclusion Even among patients with an intermediate risk of ischemic stroke (CHA2DS2-VASc score 1 for males, 2 for females) having a high risk for bleeding (HAS-BLED score ≥3), use of OACs was associated with a better clinical outcome and should still be considered.

Atrial Fibrillation and Ischemic Stroke: A Clinical Review

2021 ◽  
Author(s):  
Ibrahim Migdady ◽  
Andrew Russman ◽  
Andrew B. Buletko
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Stroke Prevention ◽  
Randomized Clinical Trials ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Strong Association ◽  
Asymptomatic Patients ◽  
Patients At Risk ◽  
Timing Of Initiation

AbstractAtrial fibrillation (AF) is an important risk factor for ischemic stroke resulting in a fivefold increased stroke risk and a twofold increased mortality. Our understanding of stroke mechanisms in AF has evolved since the concept of atrial cardiopathy was introduced as an underlying pathological change, with both AF and thromboembolism being common manifestations and outcomes. Despite the strong association with stroke, there is no evidence that screening for AF in asymptomatic patients improves clinical outcomes; however, there is strong evidence that patients with embolic stroke of undetermined source may require long-term monitoring to detect silent or paroxysmal AF. Stroke prevention in patients at risk, assessed by the CHA2DS2-VASc score, was traditionally achieved with warfarin; however, direct oral anticoagulants have solidified their role as safe and effective alternatives. Additionally, left atrial appendage exclusion has emerged as a viable option in patients intolerant of anticoagulation. When patients with AF have an acute stroke, the timing of initiation or resumption of anticoagulation for secondary stroke prevention has to be balanced against the risk of hemorrhagic conversion. Multiple randomized clinical trials are currently underway to determine the best timing for administration of anticoagulants following acute ischemic stroke.

Abstract 17373: Prescription Patterns and Outcomes of Direct Oral Anticoagulants and Warfarin in Patients With Atrial Fibrillation a Real World Analysis

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Ajoe J Kattoor ◽  
Naga venkata K Pothineni ◽  
Swathi Kovelamudi ◽  
Annette Abraham ◽  
Hakan Paydak ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Real World ◽  
Lower Incidence ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Chi Square ◽  
Prescription Patterns ◽  
Prescription Rates ◽  
Gi Bleed

Introduction: Direct Oral Anticoagulants (DOACs) are used for stroke prevention in Atrial Fibrillation (AF). Hypothesis: We sought to evaluate differences in prescription patterns of DOACs and warfarin in new onset AF patients in relation to CHA2DS2Vasc score and compare outcomes of ischemic stroke, gastrointestinal (GI) bleed and intracranial hemorrhage (ICH) between DOACs and warfarin. Methods: All patients with a new diagnosis of AF from 2014 to 2017 were identified from the admission database at the University of Arkansas for Medical Sciences, AR, U.S.A. Trends in anticoagulant prescription were plotted in relation to CHA2DS2Vasc score. Baseline characteristics were compared using t-test and chi-square test as appropriate. Multivariate logistic regression was used to identify independent predictors of clinical outcomes of interest. Results: We examined a total of 2362 patients (1306 on warfarin and 1056 on DOACs). Prescription rates of warfarin increased with increasing CHA2DS2Vasc (Fig 1). Patients on warfarin had a higher prevalence of hypertension, diabetes, heart failure, renal failure and liver disease (Table 1a). On multivariate analysis, there was no difference in the incidence of ischemic stroke and GI bleeding between warfarin and DOACs (Table 1b). However, there was a trend towards lower incidence of ICH in DOAC group (p=0.06), despite wider usage in patients with higher CHA2DS2Vasc score. Conclusions: In a real-world setting, the use of DOACs was lower in patients with high CHA2DS2Vasc score compared with warfarin. Trend towards lower incidence of ICH was present in DOAC group. Further larger studies assessing safety of DOACs in patients with high CHA2DS2Vasc are needed.

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