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

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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Abstract P146: Comparative Effectiveness Of Direct Oral Anticoagulants Versus Warfarin Among Medicare Beneficiaries With Atrial Fibrillation

Circulation ◽

10.1161/circ.143.suppl_1.p146 ◽

2021 ◽

Vol 143 (Suppl_1) ◽

Author(s):

Shirin Ardeshirrouhanifard ◽

Huijun An ◽

Ravi Goyal ◽

Mukaila Raji ◽

Caleb Alexander ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Cancer Patients ◽

Risk Model ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Competing Risk ◽

Secondary Outcome ◽

Systemic Embolism ◽

Competing Risk Model

Objective: Post-hoc analysis of three pivotal clinical trials suggests no difference in risk of ischemic stroke or systemic embolism among cancer patients with atrial fibrillation treated with direct oral anticoagulants (DOACs) vs. warfarin. However, these studies were underpowered and also do not reflect the context of real-world use. We compared the effectiveness of DOACs versus warfarin for the risk of stroke or systemic embolism and all-cause death in patients with NVAF. Methods: We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2009 to 2016 and included patients aged ≥66 years diagnosed with cancer (breast, bladder, colorectal, esophagus, lung, ovary, kidney, pancreas, prostate, stomach or uterus) and NVAF. We limited the cohort to patients who newly initiated warfarin or DOACs (from 2010 to 2016) with no history of ischemic stroke or systemic embolism. The primary outcome was hospitalization due to ischemic stroke or systemic embolism and the secondary outcome was all-cause death. We used Fine and Gray’s competing risk model, while treating death as a competing risk, to determine the association of oral anticoagulants with the incidence of stroke or systemic embolism. We also adjusted the analysis using inverse probability of treatment weighted (IPTW). Additionally, an IPTW-adjusted Cox proportional hazards regression model was constructed for all-cause death. Results: Of 1,028,784 patients with cancer, 158,744 (15.4%) were diagnosed with atrial fibrillation. After applying all inclusion criteria, the final study cohort included 7,334 cancer patients diagnosed with incident NVAF who newly initiated warfarin or DOACs, of which 3,194 (43.6%) used warfarin and 4,140 (56.4%) used DOACs. The unadjusted rate of stroke or systemic embolism was similar among warfarin and DOACs users (1.20 vs. 1.32 cases per 100 person-years, p=0.27). In the IPTW weighted competing risk model, the use of DOACs was not associated with an increased risk of stroke or systemic embolism compared with warfarin users (Hazard Ratio [HR] 1.41, 95% confidence intervals [CI] 0.90-2.20). However, DOACs users had a significantly lower risk of all-cause death compared with warfarin users (HR 0.82, CI 0.74-0.91). Conclusion: Among cancer patients diagnosed with NVAF, DOACs had a similar risk for stroke or systemic embolism compared to warfarin, although DOAC use was associated with reduced risk of all-cause mortality.

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GARFIELD-AF model for prediction of stroke and major bleeding in atrial fibrillation: a Danish nationwide validation study

BMJ Open ◽

10.1136/bmjopen-2019-033283 ◽

2019 ◽

Vol 9 (11) ◽

pp. e033283 ◽

Cited By ~ 3

Author(s):

Frederik Dalgaard ◽

Karen Pieper ◽

Freek Verheugt ◽

A John Camm ◽

Keith AA Fox ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Major Bleeding ◽

Risk Model ◽

Oral Anticoagulants ◽

External Validation ◽

Bleeding Risk ◽

Risk Scores ◽

Secondary Outcome

ObjectivesTo externally validate the accuracy of the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation (GARFIELD-AF) model against existing risk scores for stroke and major bleeding risk in patients with non-valvular AF in a population-based cohort.DesignRetrospective cohort study.SettingDanish nationwide registries.Participants90 693 patients with newly diagnosed non-valvular AF were included between 2010 and 2016, with follow-up censored at 1 year.Primary and secondary outcome measuresExternal validation was performed using discrimination and calibration plots. C-statistics were compared with CHA2DS2VASc score for ischaemic stroke/systemic embolism (SE) and HAS-BLED score for major bleeding/haemorrhagic stroke outcomes.ResultsOf the 90 693 included, 51 180 patients received oral anticoagulants (OAC). Overall median age (Q1, Q3) were 75 (66–83) years and 48 486 (53.5%) were male. At 1-year follow-up, a total of 2094 (2.3%) strokes/SE, 2642 (2.9%) major bleedings and 10 915 (12.0%) deaths occurred. The GARFIELD-AF model was well calibrated with the predicted risk for stroke/SE and major bleeding. The discriminatory value of GARFIELD-AF risk model was superior to CHA2DS2VASc for predicting stroke in the overall cohort (C-index: 0.71, 95% CI: 0.70 to 0.72 vs C-index: 0.67, 95% CI: 0.66 to 0.68, p<0.001) as well as in low-risk patients (C-index: 0.64, 95% CI: 0.59 to 0.69 vs C-index: 0.57, 95% CI: 0.53 to 0.61, p=0.007). The GARFIELD-AF model was comparable to HAS-BLED in predicting the risk of major bleeding in patients on OAC therapy (C-index: 0.64, 95% CI: 0.63 to 0.66 vs C-index: 0.64, 95% CI: 0.63 to 0.65, p=0.60).ConclusionIn a nationwide Danish cohort with non-valvular AF, the GARFIELD-AF model adequately predicted the risk of ischaemic stroke/SE and major bleeding. Our external validation confirms that the GARFIELD-AF model was superior to CHA2DS2VASc in predicting stroke/SE and comparable with HAS-BLED for predicting major bleeding.

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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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Risk of intracerebral haemorrhage in Chinese patients with atrial fibrillation on warfarin with cerebral microbleeds: the IPAAC-Warfarin study

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp-2018-319104 ◽

2018 ◽

Vol 90 (4) ◽

pp. 428-435 ◽

Cited By ~ 4

Author(s):

Yannie Soo ◽

Jill M Abrigo ◽

Kam Tat Leung ◽

Suk Fung Tsang ◽

Hing Lung Ip ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Intracerebral Haemorrhage ◽

Primary Outcome ◽

Oral Anticoagulants ◽

Final Analysis ◽

Cerebral Microbleeds ◽

Chinese Patients ◽

The Mean

Background and purposeCerebral microbleeds (CMBs), which predict future intracerebral haemorrhage (ICH), may guide anticoagulant decisions for atrial fibrillation (AF). We aimed to evaluate the risk of warfarin-associated ICH in Chinese patients with AF with CMBs.MethodsIn this prospective, observational, multicentre study, we recruited Chinese patients with AF who were on or intended to start anticoagulation with warfarin from six hospitals in Hong Kong. CMBs were evaluated with 3T MRI brain at baseline. Primary outcome was clinical ICH at 2-year follow-up. Secondary outcomes were ischaemic stroke, systemic embolism, mortality of all causes and modified Rankin Scale ≥3. Outcome events were compared between patients with and without CMBs.ResultsA total of 290 patients were recruited; 53 patients were excluded by predefined criteria. Among the 237 patients included in the final analysis, CMBs were observed in 84 (35.4%) patients, and 11 had ≥5 CMBs. The mean follow-up period was 22.4±10.3 months. Compared with patients without CMBs, patients with CMBs had numerically higher rate of ICH (3.6% vs 0.7%, p=0.129). The rate of ICH was lower than ischaemic stroke for patients with 0 to 4 CMBs, but higher for those with ≥5 CMBs. CMB count (C-index 0.82) was more sensitive than HAS-BLED (C-index 0.55) and CHA2DS2-VASc (C-index 0.63) scores in predicting ICH.ConclusionsIn Chinese patients with AF on warfarin, presence of multiple CMBs may be associated with higher rate of ICH than ischaemic stroke. Larger studies through international collaboration are needed to determine the risk:benefit ratio of oral anticoagulants in patients with AF of different ethnic origins.

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The Association of Atrial Fibrillation and Ischemic Stroke in Patients on Hemodialysis: A Competing Risk Analysis

Canadian Journal of Kidney Health and Disease ◽

10.1177/2054358119878719 ◽

2019 ◽

Vol 6 ◽

pp. 205435811987871 ◽

Cited By ~ 4

Author(s):

Mark Findlay ◽

Rachael MacIsaac ◽

Mary Joan MacLeod ◽

Wendy Metcalfe ◽

Manish M. Sood ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Stroke Risk ◽

Competing Risk ◽

Discharge Data ◽

Stroke Incidence ◽

Risk Of Death ◽

Hazards Model ◽

The Relationship

Background: Stroke is common in patients with end-stage renal disease (ESRD) treated with hemodialysis (HD) and associated with high mortality rate. In the general population, atrial fibrillation (AF) is a major risk factor for stroke and therapeutic anticoagulation is associated with risk reduction, whereas in ESRD the relationship is less clear. Objective: The purpose of this study is to demonstrate the influence of AF on stroke rates and probability in those on HD following competing risk analyses. Design: A national record linkage cohort study. Setting: All renal and stroke units in Scotland, UK. Patients: All patients with ESRD receiving HD within Scotland from 2005 to 2013 (follow-up to 2015). Measurements: Demographic, clinical, and laboratory data were linked between the Scottish Renal Registry, Scottish Stroke Care Audit, and hospital discharge data. Stroke was defined as a fatal or nonfatal event and mortality derived from national records. Methods: Associations for stroke were determined using competing risk models: the cause-specific hazards model and the Fine and Gray subdistribution hazards model accounting for the competing risk of death in models of all stroke, ischemic stroke, and first-ever stroke. Results: Of 5502 patients treated with HD with 12 348.6-year follow-up, 363 (6.6%) experienced stroke. The stroke incidence rate was 26.7 per 1000 patient-years. Multivariable regression on the cause-specific hazard for stroke demonstrated age, hazard ratio (HR) (95% confidence interval [CI]) = 1.04 (1.03-1.05); AF, HR (95% CI) = 1.88 (1.25-2.83); prior stroke, HR (95% CI) = 2.29 (1.48-3.54), and diabetes, HR (95% CI) = 1.92 (1.45-2.53); serum phosphate, HR (95% CI) = 2.15 (1.56-2.99); lower body weight, HR (95% CI) = 0.99 (0.98-1.00); lower hemoglobin, HR (95% CI) = 0.88 (0.77-0.99); and systolic blood pressure (BP), HR (95% CI) = 1.01 (1.00-1.02), to be associated with an increased stroke rate. In contrast, the subdistribution HRs obtained following Fine and Gray regression demonstrated that AF, weight, and hemoglobin were not associated with stroke risk. In both models, AF was significantly associated with nonstroke death. Limitations: Our analyses derive from retrospective data sets and thus can only describe association not causation. Data on anticoagulant use are not available. Conclusions: The incidence of stroke in HD patients is high. The competing risk of “prestroke” mortality affects the relationship between AF and risk of future stroke. Trial designs for interventions to reduce stroke risk in HD patients, such as anticoagulation for AF, should take account of competing risks affecting associations between risk factors and outcomes.

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Atrial Fibrillation, Oral Anticoagulants, and Concomitant Active Cancer: Benefits and Risks

TH Open ◽

10.1055/s-0041-1728670 ◽

2021 ◽

Vol 05 (02) ◽

pp. e176-e182

Author(s):

Adriano Atterman ◽

Leif Friberg ◽

Kjell Asplund ◽

Johan Engdahl

Keyword(s):

Atrial Fibrillation ◽

Cancer Patients ◽

Lower Risk ◽

Cox Regression ◽

Oral Anticoagulants ◽

Bleeding Events ◽

Risk Of Death ◽

Cerebrovascular Events ◽

Increased Risk ◽

Active Cancer

Abstract Aim To determine to what extent active cancer influences the benefit–risk relationship among patients with atrial fibrillation receiving oral anticoagulants for stroke prevention. Methods In this cohort study of all patients with atrial fibrillation in the Swedish Patient register during 2006 to 2017, 8,228 patients with active cancer and 323,394 without cancer were followed up to 1 year after initiation of oral anticoagulants. Cox regression models, adjusting for confounders and the competing risk of death, were used to assess risk of cerebrovascular and bleeding events. Results Among patients treated with oral anticoagulants, the risk for cerebrovascular events did not differ between cancer patients and noncancer patients (subhazard ratio [sHR]: 1.12, 95% confidence interval [CI]: 0.98–1.29). Cancer patients had a higher risk for bleedings (sHR: 1.69, CI: 1.56–1.82), but not for fatal bleedings (sHR: 1.17, CI: 0.80–1.70). Use of nonvitamin K oral anticoagulants was associated with lower risk of both cerebrovascular events and bleedings compared with warfarin. Conclusion Patients with atrial fibrillation and active cancer appear to have similar net cerebrovascular benefit of oral anticoagulant treatment to patients without cancer, despite an increased risk of nonfatal bleedings. Use of nonvitamin K oral anticoagulants was associated with lower risk of all studied outcomes.

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Multiple risk factors and ischaemic stroke in the elderly Asian population with and without atrial fibrillation

Thrombosis and Haemostasis ◽

10.1160/th15-07-0577 ◽

2016 ◽

Vol 115 (01) ◽

pp. 184-192 ◽

Cited By ~ 17

Author(s):

Hao Wang ◽

Yingchun Tian ◽

Yutao Guo ◽

Yutang Wang ◽

Gregory Y. H. Lip

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Cardiovascular Risk ◽

Ischaemic Stroke ◽

Cardiovascular Risk Factors ◽

Stroke Risk ◽

The Elderly ◽

Multiple Risk Factors ◽

Multiple Risk

SummaryIschaemic stroke risk rises with the increasing cardiovascular risk factors. How atrial fibrillation (AF) incrementally contributes to the risk for ischaemic stroke with increasing age and multiple cardiovascular risk factors is unclear. In an individual patient with AF the mechanism of ischaemic stroke may be related directly to AF itself or to risk factors associated with AF. It was this study’s objective to investigate incident ischaemic stroke in relation to age and increasing cardiovascular risk factor(s), and the incremental impact of AF on stroke rates. We studied a 5 % random sampling from Chinese medical insurance data covering more than 10 million individuals, for the years 2001 to 2012. The rate of ischaemic stroke was calculated amongst the individuals with no prior history of ischaemic stroke, in relation to age groups (aged < 65, 65–74,75 years old; n = 348,431, n = 56,952, n = 20,217, respectively), and increasing risk factors using the CHA2DS2-VASc score. Among the randomly sampled 425,600 individuals with total follow-up of 1,864,232 patient-years [63.8 % male, mean age 60 years; 880 with AF, vs 424,720 non-AF], there were 13,242 (3.1 %) ischaemic strokes after 64,834 person-years follow-up. Overall, ischaemic stroke incidence (per 100 person-years) was 0.35 (95 %CI 0.34–0.35) in the non-AF population and 1.11 (0.84–1.45) with AF. The AF population age < 65 and 65–74 had higher CHA2DS2-VASc scores than the nonAF population (p< 0.001), but this was non-significant between the non-AF and AF population age75 (p=0.086). For the population age75 years, incident stroke rates were 2.07 (0.86–4.76) and 4.29 (4.08–4.51) in non-AF and AF populations, respectively. The non-AF population age65 years with2 additional comorbidities (hyper-tension, vascular disease, diabetic, or heart failure) had ischaemic stroke rates similar to an AF population with CHA2DS2-VASc4. In both non-AF and AF populations, those with CHA2DS2-VASc =1 had a 1.9 fold increase in stroke risk, and those with CHA2DS2-VASc2 had more than four-fold increased risk for stroke, compared with those with CHA2DS2-VASc=0. In conclusion, an increasing cluster of multiple cardiovascular risk factors (besides AF) contributes to a greater risk for ischaemic stroke, especially in the elderly population. If elderly and with multiple risk factors, non-AF patients may have a risk of incident ischaemic stroke that is comparable or even higher than patients with AF, suggesting that the incremental stroke risk attributable to AF is marginal in such ‘high risk’ patients.

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A Spin-Off in Non Valvular Atrial Fibrilation (NVAF) and Cancer : Doacs As a Safe and Effective Alternative to the Convencional Avks

Blood ◽

10.1182/blood.v128.22.5021.5021 ◽

2016 ◽

Vol 128 (22) ◽

pp. 5021-5021

Author(s):

Erik Johansson ◽

Pável Olivera ◽

Tania Canals ◽

Francesc Bosch ◽

Verónica Pons ◽

...

Keyword(s):

Atrial Fibrillation ◽

Cancer Patients ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Bleeding Complications ◽

Hematological Toxicity ◽

Clinical Aspects ◽

Patients With Cancer ◽

Venous Thromboembolic Events ◽

Active Cancer

Abstract Introduction: The anticoagulation is common in patients with cancer such as treatment or prevention of venous thromboembolic events (VTE) or atrial fibrillation (AF). The evidence for the effectiveness and safety of the direct oral anticoagulants (DOACs) in those clinical setting are sparse, even more in AF patients. Aim: to analyze the effectiveness and safety of the DOACs, and other clinical aspects of patients with active cancer in the treatment of atrial fibrillation in daily clinical practice. Methods: Between Nov 2011 and May 2016 we had included consecutively adult patients with AF who initiated DOACs treatment. We selected patients with active cancer. Follow-up (FU) was an outpatient visits each 3 months and thereafter effectiveness, safety and other related to treatment data were collected. All bleeds were classified using the ISTH criteria. Results: 900 patients were included in our register where 6.1% (n=55) had an active cancer. Median age was 78 years (range 57-91) and 45.5% were women and 55.5% men. The median of creatinina clearance 59 ml/min (range 30-101). The distribution for treatment groups was: dabigatran 16.4% (n=9) with 24 months or days FU, rivaroxaban 50% (n=28) with 8 months and apixaban 32.7%(n=18) with 4 months. Ischemic strokes occurred in 16.4% of the patients with cancer (n=9).During FU, 10 patients presented bleeding complications (7.3 % minor,7.3% non-major clinically relevant and 3.6 % major bleeding according to ISTH definition).The mucocutaneous bleeding was the most common site of bleeding (30% of total bleeding) in the 5.5% drugs. In the clinical FU we observed 2 deaths, related to progression of the underlying disease. The DOACs discontinuation occurred in 16.4% (n=9) due to presence of bleeding events, hematological toxicity in chemotherapy; and worsening functio renal. The DOAC treatment was maintained concomitant with antineoplastic therapy in 83.6% (n=46) without associated complications. Conclusion: DOACs in active cancer-patients patients showed a good effectiveness and safety and they can be a great option in the treatment of NVAF, especially in those cases with unestable INR ranges.. There is an urgent need for more clinical studies in cancer patients treated with DOACs that can be candidates to these, in terms to offer them a better therapeutic options. Disclosures Bosch: Roche: Consultancy, Honoraria, Research Funding; Gilead Sciences: Membership on an entity's Board of Directors or advisory committees.

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Long-term persistence and adherence with non-vitamin K oral anticoagulants in patients with atrial fibrillation and their associations with stroke risk

European Heart Journal - Cardiovascular Pharmacotherapy ◽

10.1093/ehjcvp/pvaa017 ◽

2020 ◽

Cited By ~ 2

Author(s):

Joris J Komen ◽

Eibert R Heerdink ◽

Olaf H Klungel ◽

Aukje K Mantel-Teeuwisse ◽

Tomas Forslund ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Stroke Risk ◽

Oral Anticoagulants ◽

Early Years ◽

Poor Adherence ◽

Healthcare Database ◽

Persistence Rates

Abstract Aims Studies on adherence and persistence with non-vitamin K oral anticoagulant (NOAC) treatment have relied on data from the early years of NOAC availability. We aimed to study long-term adherence and persistence with NOACs and their association with stroke risk. Methods and results From the Stockholm Healthcare database, we included 21 028 atrial fibrillation patients claiming a first NOAC prescription from July 2011 until October 2018, with more than 1000 patients having more than 5 years of follow-up (median: 2.0, interquartile range: 1.0–3.2). Persistence rates, defined as continuing to claim NOAC prescriptions within a 90-day gap, decreased to 70% at the end of follow-up. However, 85% of the patients were treated at the end of the study due to reinitiations. Adherence, calculated as medication possession rate (MPR) in 3 and 6-month intervals among persistent users, remained stable at 90%, with 75% of patients having an MPR >95% throughout the study period. Using a case–control design, we calculated associations of persistence and adherence with stroke risk, adjusting for potential confounders. The outcome was a composite of ischaemic or unspecified stroke and transient ischaemic attack. Non-persistence and poor adherence were both associated with increased stroke risk [non-persistence adjusted odds ratio (aOR): 2.05; 95% confidence interval (CI): 1.49–2.82, 1% reduction MPR aOR: 1.03; CI: 1.01–1.05]. There was no association between non-persistence or poor adherence and the falsification endpoints; fractions and respiratory infections, indicating no ‘healthy-adherer’ effect. Conclusion Persistence rates decreased slowly over time, but persistent patients had high adherence rates. Both non-persistence and poor adherence were associated with an increased stroke risk.

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Dynamic Changes of CHA2DS2-VASc Score and the Risk of Ischaemic Stroke in Asian Patients with Atrial Fibrillation: A Nationwide Cohort Study

Thrombosis and Haemostasis ◽

10.1055/s-0038-1651482 ◽

2018 ◽

Vol 118 (07) ◽

pp. 1296-1304 ◽

Cited By ~ 44

Author(s):

Minjae Yoon ◽

Pil-Sung Yang ◽

Eunsun Jang ◽

Hee Yu ◽

Tae-Hoon Kim ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Ischaemic Stroke ◽

Stroke Risk ◽

Low Risk ◽

Dynamic Changes ◽

Risk Patients ◽

Changes Over Time ◽

Over Time

Background Stroke risk in atrial fibrillation (AF) is often assessed at initial presentation, and risk stratification performed as a ‘one off’. In validation studies of risk prediction, baseline values are often used to ‘predict’ events that occur many years later. Many clinical variables have ‘dynamic’ changes over time, as the patient is followed up. These dynamic changes in risk factors may increase the CHA2DS2-VASc score, stroke risk category and absolute ischaemic stroke rate. Objective This article evaluates the ‘dynamic’ changes of CHA2DS2-VASc variables and its effect on prediction of stroke risk. Patients and Methods From the Korea National Health Insurance Service database, a total of 167,262 oral anticoagulant-naive non-valvular AF patients aged ≥ 18 years old were enrolled between January 1, 2002, and December 31, 2005. These patients were followed up until December 31, 2015. Results At baseline, the proportions of subjects categorized as ‘low’, ‘intermediate’ or ‘high risk’ by CHA2DS2-VASc score were 15.4, 10.6 and 74.0%, respectively. Mean CHA2DS2-VASc score increased annually by 0.14, particularly due to age and hypertension. During follow-up of 10 years, 46.6% of ‘low-risk’ patients and 72.0% of ‘intermediate risk’ patients were re-classified to higher stroke risk categories. Among the original ‘low-risk’ patients, annual ischaemic stroke rates were significantly higher in the re-classified ‘intermediate’ (1.17 per 100 person-years, p < 0.001) or re-classified ‘high-risk’ groups (1.44 per 100 person-years, p = 0.048) than consistently ‘low-risk’ group (0.29 per 100 person-years). The most recent CHA2DS2-VASc score and the score change with the longest follow-up had the best prediction for ischaemic stroke. Conclusion In AF patients, stroke risk as assessed by the CHA2DS2-VASc score is dynamic and changes over time. Rates of ischaemic stroke increased when patients accumulated risk factors, and were re-classified into higher CHA2DS2-VASc score categories. Stroke risk assessment is needed at every patient contact, as accumulation of risk factors with increasing CHA2DS2-VASc score translates to greater stroke risks over time.

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