Oral anticoagulation in atrial fibrillation patients at intermediate risk of stroke: a nationwide registry-based cohort (Atrial Fibrillation in Norway – AFNOR)

Abstract Background The effect of oral anticoagulants (OAC) on prevention of stroke must be carefully balanced against the potential risk of bleeding in patients with atrial fibrillation (AF). The net benefit of OAC in AF patients at intermediate risk of stroke remains unclear. Aim We aimed to determine whether the rates of ischemic and haemorrhagic stroke differ between users and non-users of OAC in a nationwide cohort of AF patients at intermediate risk of stroke. Method We investigated the association between initiation of OAC treatment and rates of ischemic and haemorrhagic stroke in a cohort of Norwegian patients with non-valvular AF aged ≥18 years with one non-sex CHA2DS2-VASc risk factor registered from 2011 to 2018, linking data from the Norwegian Population Registry, Patient Registry, Prescription Database and Cause of Death Registry. Individuals using OAC at baseline were excluded. Each individual had at least a three years look-back period for identification of their first non-sex CHA2DS2-VASc risk factor, after which they entered the study cohort and were followed until occurrence of stroke, death, emigration, higher CHA2DS2-VASc score or end of follow-up on December 31, 2018. Individuals were defined as exposed to OAC from the first redeemed prescription of OAC with a reimbursement code for AF and throughout follow-up. Rates of ischemic and haemorrhagic stroke were calculated as the number of stroke cases per 100 person-years, with 95% confidence intervals (CI). Results During 2011–2018, a total of 61,631 individuals with AF and intermediate risk of stroke were included (mean age 63,8±7,6 years (SD); 37% women), of whom 75% initiated OAC treatment. In total, 1709 ischemic strokes (405 cases in OAC users and 1304 in non-users) were registered during 214,738 person-years, and 378 haemorrhagic strokes (251 cases in OAC users and 127 in non-users) during 213,487 person-years. The rate of ischemic stroke was 0.39 (95% CI, 0.35–0.43) and 1.19 (95% CI, 1.12–1.25) per 100 person-years in OAC users and non-users, respectively. The haemorrhagic stroke rate was 0.24 (95% CI, 0.21–0-27) and 0.12 (95% CI, 0.10–0.14) per 100 person-years in OAC users and non-users, respectively. Both ischemic and haemorrhagic stroke rates were highest among those over 65 years of age (Figure 1). Conclusion In a nationwide cohort of Norwegian AF patients at intermediate risk of stroke, three out of four initiated treatment with OAC. Use of OAC was associated with a considerably lower rate of ischemic stroke compared to non-OAC use. Although haemorrhagic stroke rates were increased in the OAC-users vs. non-users, the hemorrhagic stroke rates were generally low. FUNDunding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Vestre Viken Health Trust Figure 1. Rates of ischemic and haemorrhagic stroke per 100 person-years in AF-patients at intermediate risk of stroke (CHA2DS2-VASc score 1 in men, score 2 in women) by OAC use during 2011 to 2018. Age corresponds to age at attainment of the first non-sex CHA2DS2-VASc risk factor.

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P4776Age-dependent anti-thrombotic therapy for atrial fibrillation patients with intermediate risk (CHA2DS2-VASc Score of 1 or 2) of ischemic stroke

European Heart Journal ◽

10.1093/eurheartj/ehz745.1152 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

K M Lee ◽

M H Kim ◽

S Y Choi ◽

S J Kim ◽

S W Kim ◽

...

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Ischemic Stroke ◽

Oral Anticoagulants ◽

Intermediate Risk ◽

Risk Criterion ◽

Korean National Health Insurance ◽

Effect Of Age ◽

Annual Risk

Abstract Background Although older age is one of the most important risk factor for stroke in atrial fibrillation (AF), it is unclear whether oral anticoagulants are beneficial for AF patients with intermediate CHA2DS2-VASc score (1 for male or 2 for female) according to age threshold. We sought to investigate the effect of age-dependent antithrombotic therapy for ischemic stroke in Korean intermediate risk AF patients. Methods We enrolled 29,592 patients (males with CHA2DS2-VASc score of 1 and females with CHA2DS2-VASc score of 2) using the Korean National Health Insurance Service database. The clinical endpoint was the occurrence of ischemic stroke. The propensity score matching method was used to balance covariates across treated and untreated patients. Results Treated male AF patients were 6,570 (67.1%) with age <55 years, 7,115 (70.9%) with 55–64 years and 6,470 (68.3%) with 65–74 years in each age risk criterion. Also, treated female AF patients were 3,156 (71.3%) with age <55 years, 2,838 (71.0%) with 55–64 years and 3,440 (72.6%) with 65–74 years in each age risk criterion. Among male and female patients (age <55 years and 55–64 years) with 1 risk factor, an annual ischemic stroke rate was not significantly different between treated and untreated patients at full follow-up. However, treated AF patients who are in age 65–74 year without other risk factor had a much lower annual risk of ischemic stroke [(1.05%/year (male) and 1.04%/year (female)] compared with untreated patients [(1.77%/year (male) (p<0.026) and 1.86%/year (female) (p<0.041). Conclusions Age is an important predictor in determining the risk of ischemic stroke in AF patients with intermediate CHA2DS2-VASc scores (1 for male or 2 for female). We suggest that the benefit of anti-thrombotic therapy for intermediate risk AF patients depends on age threshold.

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Anticoagulant therapy in practice

Orvosi Hetilap ◽

10.1556/oh.2012.29357 ◽

2012 ◽

Vol 153 (19) ◽

pp. 732-736

Author(s):

Gergely Hofgárt ◽

Csilla Vér ◽

László Csiba

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Ischemic Stroke ◽

Acute Stroke ◽

Anticoagulant Therapy ◽

Oral Anticoagulants ◽

Health Science ◽

Science Centre ◽

Improper Use ◽

Current Guidelines

Atrial fibrillation is a risk factor for ischemic stroke. To prevent stroke oral anticoagulants can be administered. Old and new types of anticoagulants are available. Nowadays, old type, acenocumarol based anticoagulants are used preferentially in Hungary. Aim: The advantages and the disadvantages of anticoagulants are well known, but anticoagulants are underused in many cases. Method: The authors retrospectively examined how frequent atrial fibrillation was and whether the usage of anticoagulants in practice was in accordance with current guidelines among acute stroke cases admitted to the Department of Neurology, Medical and Health Science Centre of Debrecen University in 2009. Results: Of the 461 acute stroke cases, 96 patients had known and 22 patients had newly discovered atrial fibrillation. Half of the patients did not receive proper anticoagulation. Only 8.4% of them had their INR levels within the therapeutic range. Conclusions: The findings are similar to those reported in other studies. Many factors may contribute to the high proportion of improper use of anticoagulants, and further investigations are needed to determine these factors. In any case, elimination of these factors leading to a failure of anticoagulation may decrease the incidence of stroke. Orv. Hetil., 2012, 153, 732–736.

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The Number of Concomitant Drugs and the Safety of Direct Oral Anticoagulants in Routine Care Patients with Atrial Fibrillation

TH Open ◽

10.1055/s-0040-1721499 ◽

2020 ◽

Vol 04 (04) ◽

pp. e417-e426

Author(s):

Carline J. van den Dries ◽

Sander van Doorn ◽

Patrick Souverein ◽

Romin Pajouheshnia ◽

Karel G.M. Moons ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Major Bleeding ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Routine Care ◽

P Value ◽

Risk Of Mortality ◽

Mortality Effect

Abstract Background The benefit of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) on major bleeding was less prominent among atrial fibrillation (AF) patients with polypharmacy in post-hoc randomized controlled trials analyses. Whether this phenomenon also exists in routine care is unknown. The aim of the study is to investigate whether the number of concomitant drugs prescribed modifies safety and effectiveness of DOACs compared with VKAs in AF patients treated in general practice. Study Design Adult, nonvalvular AF patients with a first DOAC or VKA prescription between January 2010 and July 2018 were included, using data from the United Kingdom Clinical Practice Research Datalink. Primary outcome was major bleeding, secondary outcomes included types of major bleeding, nonmajor bleeding, ischemic stroke, and all-cause mortality. Effect modification was assessed using Cox proportional hazard regression, stratified for the number of concomitant drugs into three strata (0–5, 6–8, ≥9 drugs), and by including the continuous variable in an interaction term with the exposure (DOAC vs. VKA). Results A total of 63,600 patients with 146,059 person-years of follow-up were analyzed (39,840 person-years of DOAC follow-up). The median age was 76 years in both groups, the median number of concomitant drugs prescribed was 7. Overall, the hazard of major bleeding was similar between VKA-users and DOAC-users (hazard ratio [HR] 0.98; 95% confidence interval [CI] 0.87–1.11), though for apixaban a reduction in major bleeding was observed (HR 0.81; 95% CI 0.68–0.98). Risk of stroke was comparable, while risk of nonmajor bleeding was lower in DOAC users compared with VKA users (HR 0.92; 95% CI 0.88–0.97). We did not observe any evidence for an impact of polypharmacy on the relative risk of major bleeding between VKA and DOAC across our predefined three strata of concomitant drug use (p-value for interaction = 0.65). For mortality, however, risk of mortality was highest among DOAC users, increasing with polypharmacy and independent of the type of DOAC prescribed (p-value for interaction <0.01). Conclusion In this large observational, population-wide study of AF patients, risk of bleeding, and ischemic stroke were comparable between DOACs and VKAs, irrespective of the number of concomitant drugs prescribed. In AF patients with increasing polypharmacy, our data appeared to suggest an unexplained yet increased risk of mortality in DOAC-treated patients, compared with VKA recipients.

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Abstract 2646: Aortic Arch Plaques and Risk of Vascular Events in Subjects Without Prior Stroke

Circulation ◽

10.1161/circ.118.suppl_18.s_760 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Cesare Russo ◽

Zhezhen Jin ◽

Ralph L Sacco ◽

Shunichi Homma ◽

Tatjana Rundek ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Aortic Arch ◽

Proportional Hazards ◽

Cox Proportional Hazards ◽

Study Cohort ◽

Vascular Events ◽

Increased Risk ◽

Prior Stroke

BACKGROUND: Aortic arch plaques (AAP) are a risk factor for cardiovascular embolic events. However, the risk of vascular events associated with AAP in the general population is unclear. AIM: To assess whether AAP detected by transesophageal echocardiography (TEE) are associated with an increased risk of vascular events in a stroke-free cohort. METHODS: The study cohort consisted of stroke-free subjects over age 50 from the Aortic Plaques and Risk of Ischemic Stroke (APRIS) study. AAP were assessed by multiplane TEE, and considered large if ≥ 4 mm in thickness. Vascular events including myocardial infarction, ischemic stroke and vascular death were recorded during the follow-up. The association between AAP and outcomes was assessed by univariate and multivariate Cox proportional hazards models. RESULTS: A group of 209 subjects was studied (mean age 67±9 years; 45% women; 14% whites, 30% blacks, 56% Hispanics). AAP of any size were present in 130 subjects (62%); large AAP in 50 (24%). Subjects with AAP were older (69±8 vs. 63±7 years), had higher systolic BP (146±21 vs.139±20 mmHg), were more often white (19% vs. 8%), smokers (20% vs. 9%) and more frequently had a history of coronary artery disease (26% vs. 14%) than those without AAP (all p<0.05). Lipid parameters, prevalence of atrial fibrillation and diabetes mellitus were not significantly different between the two groups. During the follow up (94±29 months) 30 events occurred (13 myocardial infarctions, 11 ischemic strokes, 6 vascular deaths). After adjustment for other risk factors, AAP of any size were not associated with an increased risk of combined vascular events (HR 1.07, 95% CI 0.44 to 2.56). The same result was observed for large AAP (HR 0.94, CI 0.34 to 2.64). Age (HR 1.05, CI 1.01 to 1.10), body mass index (HR 1.08, CI 1.01 to 1.15) and atrial fibrillation (HR 3.52, CI 1.07 to 11.61) showed independent association with vascular events. In a sub-analysis with ischemic stroke as outcome, neither AAP of any size nor large AAP were associated with an increased risk. CONCLUSIONS: In this cohort without prior stroke, the incidental detection of AAP was not associated with an increased risk of future vascular events. Associated co-factors may affect the AAP-related risk of vascular events reported in previous studies.

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Study of Outcome of Ischemic Stroke Patient With Atrial Fibrillation

TAJ Journal of Teachers Association ◽

10.3329/taj.v28i2.39072 ◽

2018 ◽

Vol 28 (2) ◽

pp. 1-6

Author(s):

Achinta Kumar Mallick ◽

Md Kafil Uddin ◽

Md Ahmed Ali ◽

Pijus Kumar Kundu ◽

Sheikh Mohammad Emdadul Haque ◽

...

Keyword(s):

Atrial Fibrillation ◽

Risk Factor ◽

Ischemic Stroke ◽

Linear Regression Analysis ◽

Clinical Deterioration ◽

Stroke Recurrence ◽

Stroke Severity ◽

Multivariate Linear Regression Analysis ◽

Stroke Patients

Atrial fibrillation (AF) is a common arrhythmia and a major risk factor for ischemic stroke, especially in the elderly. Patients with nonvalvular AF have a 5-fold excess risk of stroke. However, population-based data are scarce in patients who have experienced a first-ever ischemic stroke in the presence of AF regarding long-term risk of stroke recurrence and case-fatality rate. Aim of the study is to find out the outcome of ischemic stroke patients with Atrial Fibrillation. It was a descriptive type cross sectional study where 125 diagnosed cases of ischemic stroke were included. Presence of atrial fibrillation was detected by electrocardiogram. They were divided into two groups – those with atrial fibrillation and those without. Comparison was done between the two group in term of recurrence, mortality and clinical improvement. Atrial fibrillation was present in 22 (17.6%) of 125 patients with ischemic stroke. Those with AF were more frequently male, aged 45 years and older. The presence of AF was associated with high 3 months (Χ2 =4.562, df = 1, p<0.05) and 6 months mortality (Χ2 =7.868, df = 1, p<0.05), with a higher stroke recurrence rate within the first 6 months follow-up (22.7% versus 7.8% (<0.05)). At 3 months follow up clinical deterioration was noted in 9.1% patient with atrial fibrillation compared to 2.9% patients who had no arrhythmia(p<0.01) and at 6 months follow up clinical deterioration was noted in 18.2% patient with atrial fibrillation compared to 4.9% patients who had no arrhythmia(p<0.01). Ischemic stroke patients with atrial fibrillation had significant mortality within the study period compared to those without atrial fibrillation. Significant deterioration in clinical outcome was noted in atrial fibrillation group after six months. Recurrence was more in ischemic stroke patients with atrial fibrillation. Multivariate linear regression analysis shows atrial fibrillation as well as CKD, Diabetes mellitus and smoking as independent risk factor for recurrence. In conclusion, patients who had an ischemic stroke with accompanying atrial fibrillation had higher mortality, grave stroke severity, more recurrences and poorer functional status than those without atrial fibrillation.TAJ 2015; 28(2): 1-6

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Atrial Fibrillation Detected by Single Timepoint Handheld ECG Screening and the Risk of Ischemic Stroke

Thrombosis and Haemostasis ◽

10.1055/a-1588-8867 ◽

2021 ◽

Author(s):

Wen Sun ◽

Ben FREEDMAN ◽

Carlos Martinez ◽

Christopher Wallenhorst ◽

Bryan Yan

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Multivariate Regression ◽

Stroke Risk ◽

Oral Anticoagulants ◽

Outpatient Clinics ◽

Initial Screening ◽

Hazard Ratios ◽

Ischemic Stroke Risk

ABSTRACT Objective: We evaluated stroke risk in patients with single timepoint screen-detected atrial fibrillation (AF) and the effect of oral anticoagulants (OAC). Methods: Consecutive patients aged ≥65 years attending medical outpatient clinics were prospectively enrolled for AF-screening using handheld single-lead ECG (AliveCor) from 12/2014 to 12/2017 (NCT02409654). Repeated screening was performed in patients with >1 visit during this period. Three cohorts were formed, screen-detected AF, clinically-diagnosed AF and no AF. Ischemic stroke risk was estimated using adjusted sub-distribution hazard ratios (aSHR) from multivariate regression and no AF as reference, and stratified according to OAC use. Results: Of 11,972 subjects enrolled, 2,238 (18.7%) had clinically-diagnosed AF at study enrollment. The yield of screen-detected AF on initial screening was 2.3% (n=223/9,734). AF was clinically-diagnosed during follow-up in 2.3% (n=216/9,440) and during subsequent screening in 71 initially screen-negative patients. Compared to no AF, patients with screen-detected AF without OAC treatment had the highest stroke risk (aSHR 2.63; 95% confidence interval 1.46-4.72), while aSHR for clinically-diagnosed AF without OAC use was 2.01 (1.54-2.62). Among screen-detected AF the risk of stroke was significantly less with OAC (no strokes in 196 person-years) compared with those not given OAC (12 strokes in 429 person-years), p=0.01. Conclusion: The prognosis of single timepoint ECG screen-detected AF is not benign. The risk of stroke is high enough to warrant OAC use, and reduced by OAC. Keywords: atrial fibrillation, screening, ischemic stroke

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Age-dependent anticoagulant therapy for atrial fibrillation patients with intermediate risk of ischemic stroke: A nationwide population-based study

Thrombosis and Haemostasis ◽

10.1055/a-1336-0476 ◽

2020 ◽

Author(s):

Sun Young Choi ◽

Moo Hyun Hyun Kim ◽

Kwang Min Lee ◽

Young-Rak Cho ◽

Jong Sung Park ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Lower Risk ◽

Oral Anticoagulants ◽

Population Based ◽

Intermediate Risk ◽

Composite Outcome ◽

Population Based Study ◽

Age Dependent ◽

Korean National Health Insurance

Background: Although older age is one of the most important risk factors for stroke in atrial fibrillation (AF), it is unclear whether an age threshold exists for which oral anticoagulants (OACs) are beneficial for intermediate-risk AF patients. We sought to investigate the age-dependency of OAC for ischemic stroke in intermediate-risk AF patients. Methods: We enrolled 34,701 AF patients (males with a CHA2DS2-VASc score of 1 and females with a CHA2DS2-VASc score of 2) using the Korean National Health Insurance Service database. The clinical endpoint was the occurrence of ischemic stroke and a composite outcome (ischemic stroke + major bleeding + all-cause death). Results: In AF patients aged ≥ 55 years, OAC therapy was associated with a lower risk of ischemic stroke compared with non-OAC treatment in males (55-59 years: HR 0.79, 95% CI 0.61-0.98, p = 0.038, 60-64 years: HR 0.78, 95% CI 0.61-0.96, p = 0.029, and 65-74 years: HR 0.66, 95% CI 0.49-0.84, p = 0.011) and females (55-59 years: HR 0.76, 95% CI 0.58-0.96, p = 0.027, 60-64 years: HR 0.73, 95% CI 0.55-0.93, p = 0.017, and 65-74 years: HR 0.69, 95% CI 0.51-0.87, p = 0.013). OAC was associated with a lower risk for the composite outcome compared to non-OAC for male and female patients aged ≥ 55 years. Conclusions: Age is an important determinant of ischemic stroke and composite outcome in intermediate-risk AF patients. The benefit of OAC therapy for these AF patients appears to have an age threshold (age ≥ 55 years).

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Comparative Effectiveness of Rivaroxaban, Apixaban, and Warfarin in Atrial Fibrillation Patients With Polypharmacy

Stroke ◽

10.1161/strokeaha.120.029541 ◽

2020 ◽

Vol 51 (7) ◽

pp. 2076-2086 ◽

Cited By ~ 1

Author(s):

Amgad Mentias ◽

Eric Heller ◽

Mary Vaughan Sarrazin

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Comparative Effectiveness ◽

Oral Anticoagulants ◽

Bleeding Risk ◽

Hazard Ratio ◽

Adjusted Hazard Ratio ◽

Study Cohort ◽

Prescription Medications ◽

Risk Of Death

Background and Purpose: Comparative effectiveness and safety of oral anticoagulants in patients with atrial fibrillation and high polypharmacy are unknown. Methods: We used Medicare administrative data to evaluate patients with new atrial fibrillation diagnosis from 2015 to 2017, who initiated an oral anticoagulant within 90 days of diagnosis. Patients taking ≤3, 4 to 8, or ≥9 other prescription medications were categorized as having low, moderate, or high polypharmacy, respectively. Within polypharmacy categories, patients receiving apixaban 5 mg twice daily, rivaroxaban 20 mg once daily, or warfarin were matched using a 3-way propensity score matching. Study outcomes included ischemic stroke, bleeding, and all-cause mortality. Results: The study cohort included 6985 patients using apixaban, 3838 using rivaroxaban, and 6639 using warfarin. In the propensity-matched cohorts there was no difference in risk of ischemic stroke between the 3 drugs in patients with low and moderate polypharmacy. However, among patients with high polypharmacy, the risk of ischemic stroke was higher with apixaban compared with warfarin (adjusted hazard ratio 2.34 [95% CI, 1.01–5.42]; P =0.05) and similar to rivaroxaban (adjusted hazard ratio, 1.38 [95% CI, 0.67–2.84]; P =0.4). There was no difference in risk of death between the 3 drugs in patients with low and moderate polypharmacy, but apixaban was associated with a higher risk of death compared with rivaroxaban (adjusted hazard ratio, 2.03 [95% CI, 1.01–4.08]; P =0.05) in the high polypharmacy group. Apixaban had lower bleeding risk compared with warfarin in the low polypharmacy group (adjusted hazard ratio, 0.54 [95% CI, 0.32–0.90]; P =0.02), but there was no difference in bleeding between the 3 drugs in the moderate and high polypharmacy groups. Conclusions: Our study suggests that among patients with significant polypharmacy (>8 drugs), there may be a higher stroke and mortality risk with apixaban compared with warfarin and rivaroxaban. However, differences were of borderline significance.

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Use of Idarucizumab in Ischemic Stroke: A National Experience in a Middle Income Country and a Concise Review.

10.21203/rs.3.rs-589277/v1 ◽

2021 ◽

Author(s):

Julián Alejandro Rivillas ◽

Arango Akemi ◽

Bayona Hernán ◽

Jaramillo Eugenia ◽

Amaya Pablo

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Acute Stroke ◽

Combined Therapy ◽

Oral Anticoagulants ◽

Middle Income Country ◽

Income Country ◽

Middle Income ◽

Stroke Treatment

Abstract Background Despite receiving anticoagulation for primary or secondary prevention for atrial fibrillation, new embolic events may occur. Current stroke guidelines contraindicate the use of thrombolysis if oral anticoagulants are used within 48 hours of symptom onset. Idarucizumab may be an alternative for patients receiving dabigatran with an acute stroke when alteplase is indicated. We present a series of four cases of patients who received idarucizumab in neurological emergencies in a middle-income country in Latin America. Methods Using the national pharmacologic surveillance data, we retrospectively collected the cases of idarucizumab used in acute stroke, including retinal thrombosis in Colombia between 2018 and 2020. Results Four male patients with atrial fibrillation received thrombolysis for acute stroke, and two of them received mechanical thrombectomy. No major complications during hospitalization were present. One of the patients that received combined therapy presented with hematuria; the other patient that received thrombolysis presented with groin hematoma, but none required transfusion. All had favorable mRS at discharge and 90-day follow-up. Conclusion The use of thrombolysis after reversal with idarucizumab in patients with ischemic stroke is safe. Our patients presented favorable mRS at discharge and 90-day follow-up. The low number of cases is related to the poor availability of idarucizumab. Only 11 hospitals in 5 cities have storage of the medication. Stronger public policies are needed to guarantee optimal stroke treatment in patients with atrial fibrillation receiving anticoagulation, including access to reversal and reperfusion therapies to reduce further disability, especially in a middle-income country such as Colombia.

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Net benefit of oral anticoagulants in patients with atrial fibrillation and active cancer: a nationwide cohort study

EP Europace ◽

10.1093/europace/euz306 ◽

2019 ◽

Author(s):

Adriano Atterman ◽

Leif Friberg ◽

Kjell Asplund ◽

Johan Engdahl

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Cancer Patients ◽

Stroke Risk ◽

Oral Anticoagulants ◽

Competing Risk ◽

Net Benefit ◽

Outpatient Unit ◽

Active Cancer

Abstract Aims To estimate the net cerebrovascular benefit of prophylactic treatment with oral anticoagulants (OACs) in patients with atrial fibrillation (AF) and active cancer. Methods and results We included all Swedish patients who had been diagnosed with AF in a hospital or in a hospital-associated outpatient unit between 1 July 2005 and 1 October 2017. Patients with active cancer (n = 22 596) and without cancer (n = 440 848) were propensity score matched for the likelihood of receiving OACs at baseline. At baseline, 38.3% of cancer patients with AF and high stroke risk according to CHA2DS2-VASc score received OACs. There was a net benefit of OACs, assessed by the composite outcome of ischaemic stroke, extracranial arterial thromboembolism, all major bleedings, and death, both among patients with active cancer [hazard ratio (HR): 0.81, confidence interval (CI): 0.78–0.85] and among patients without cancer (HR: 0.81, CI: 0.80–0.82). When limiting follow-up to 1 year to minimize the effects of possible treatment cross-over and additionally accounting for death as a competing risk in cancer patients, a net cerebrovascular benefit regarding ischaemic stroke or intracranial bleeding was observed for OACs [subhazard ratio (sHR): 0.67, CI: 0.55–0.83]. A net cerebrovascular benefit was also seen for non-vitamin K antagonist OACs over warfarin after competing risk analyses in cancer patients (sHR: 0.65, CI: 0.48–0.88). Conclusion Patients with AF and active cancer benefit from OAC treatment.

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