Abstract 14022: Effect of Discontinuation and Nonadherence to Oral Anticoagulants on Atrial Fibrillation Stroke Risk

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Xiaoxi Yao ◽  
Neena S Abraham ◽  
Peter A Noseworthy ◽  
G. Caleb Alexander ◽  
Lindsey R Sangaralingham ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Oral Anticoagulants ◽  
Baseline Risk ◽  
Predicted Probability ◽  
Increased Risk ◽  
Risk Patients ◽  
Cox Proportional Hazard Models ◽  
One Year ◽  
Ischemic Attack

Introduction: Medicines don’t work in those who don’t take them. Although novel oral anticoagulants (NOACs) are more convenient than warfarin due to fewer drug-drug interactions and less need for laboratory monitoring, their considerable costs and lack of regular interactions with the healthcare system may also contribute to poor adherence. Little is known about the persistence and adherence in the era of NOACs, nor how such behaviors are associated with the risk of ischemic stroke and transient ischemic attack (TIA) among patients of varying baseline risk. Methods: We conducted a retrospective analysis using a large U.S. commercial insurance database, and identified 61,646 patients with atrial fibrillation who initiated one of OACs (warfarin, dabigatran, rivaroxaban and apixaban) between October 2010 and September 2014. We defined discontinuation as being off OACs for at least 3 months and adherence as the proportion of days covered of at least 80%. Cox proportional hazard models was used to examine whether the time that patients were off OACs, including both the gaps between medication fills and the time of discontinuation, increased the risk of ischemic stroke and TIA. Results: Approximately 1 in 3 patients discontinued OACs within one year after initiation and 1 in 10 switched to another OAC. The estimated likelihood of adherence was 0.77 during the time when patients were on their first-line medications. Apixaban had the highest continuation rate (65% at 1 year), while rivaroxaban had the best adherence (predicted probability of adherence 0.83). The event rate of stroke was 1.6 per 100 person years. Patients with high baseline risk (CHA2DS2-VASc ≥2) were more likely to have a stroke when they were off OACs for 1-3 months (HR=1.47, p<0.01), 3-6 months (HR=1.78, p<0.001) and ≥6 months (HR=2.16, p<0.001), compared to off OACs for less than a week. No significant effect was found among low-risk patients (CHA2DS2-VASc 0 or 1). Switching to another OAC was related to 22% increased risk of stroke (p=0.05). Conclusions: Despite their greater convenience relative to warfarin, discontinuation and nonadherence to NOACs is high. Lack of persistence and adherence was associated with increased risk of ischemic stroke and TIA among patients with elevated baseline risk.

scholarly journals High ABCD2 Scores and In-Hospital Interventions following Transient Ischemic Attack

2016 ◽  
Vol 6 (3) ◽  
pp. 76-83 ◽  
Author(s):  
Shawna Cutting ◽  
Elizabeth Regan ◽  
Vivien H. Lee ◽  
Shyam Prabhakaran
Keyword(s):  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Heart Association ◽  
Reperfusion Therapy ◽  
Large Artery ◽  
Increased Risk ◽  
Risk Patients ◽  
Abcd2 Score ◽  
Ischemic Attack ◽  
Ischemic Events

Background and Purpose: Following transient ischemic attack (TIA), there is increased risk for ischemic stroke. The American Heart Association recommends admission of patients with ABCD2 scores ≥3 for observation, rapid performance of diagnostic tests, and potential acute intervention. We aimed to determine if there is a relationship between ABCD2 scores, in-hospital ischemic events, and in-hospital treatments after TIA admission. Methods: We reviewed consecutive patients admitted between 2006 and 2011 following a TIA, defined as transient focal neurological symptoms attributed to a specific vascular distribution and lasting <24 h. Three interventions were prespecified: anticoagulation for atrial fibrillation, carotid or intracranial revascularization, and intravenous or intra-arterial reperfusion therapies. We compared rates of in-hospital recurrent TIA or ischemic stroke and the receipt of interventions among patients with low (<3) versus high (≥3) ABCD2 scores. Results: Of 249 patients, 11 patients (4.4%) had recurrent TIAs or strokes during their stay (8 TIAs, 3 strokes). All 11 had ABCD2 scores ≥3, and no neurological events occurred in patients with lower scores (5.1 vs. 0%; p = 0.37). Twelve patients (4.8%) underwent revascularization for large artery stenosis, 16 (6.4%) were started on anticoagulants, and no patient received intravenous or intra-arterial reperfusion therapy. The ABCD2 score was not associated with anticoagulation (p = 0.59) or revascularization (p = 0.20). Conclusions: Higher ABCD2 scores may predict early ischemic events after TIA but do not predict the need for intervention. Outpatient evaluation for those with scores <3 would potentially have delayed revascularization or anticoagulant treatment in nearly one-fifth of ‘low-risk' patients.

scholarly journals Bleeding and thromboembolism due to drug-drug interactions with non-vitamin K antagonist oral anticoagulants—a Swedish, register-based cohort study in atrial fibrillation outpatients

2020 ◽  
Author(s):  
Johan Holm ◽  
Buster Mannheimer ◽  
Rickard E Malmström ◽  
Erik Eliasson ◽  
Jonatan D Lindh
Keyword(s):  
Atrial Fibrillation ◽  
Cohort Study ◽  
Ischemic Stroke ◽  
Vitamin K ◽  
Cox Regression ◽  
Oral Anticoagulants ◽  
Outcome Data ◽  
Vitamin K Antagonist ◽  
Drug Register ◽  
Increased Risk

Abstract Purpose To study the association between interacting drugs and bleeding or thromboembolism in atrial fibrillation outpatients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Methods Population-based cohort study of outpatients treated with NOACs in Sweden from 2008 to 2017. Patients with atrial fibrillation and newly initiated NOAC treatment were identified in the Prescribed Drug Register. Comorbidities and outcome data were retrieved from the Patient Register and the Cause of Death Register. Cox-regression analyses were performed to evaluate the primary endpoints any severe bleed and ischemic stroke/transient ischemic attack/stroke unspecified during the first six months of treatment. Secondary endpoints were gastrointestinal bleeding, intracranial bleeding, ischemic stroke, and venous thromboembolism. Results Increased risk of any severe bleed was found when NOAC treatment, and drugs with pharmacodynamic effect on bleeding were combined, compared to NOAC only. An increased risk with these combinations was evident for apixaban (hazard ratio (HR) 1.47; 95% CI 1.33–1.63), rivaroxaban (HR 1.7; 95% CI 1.49–1.92), and dabigatran (HR 1.26; 95% CI 1.05–1.52). For apixaban, there was an increased risk of any severe bleed when combined with CYP3A4 and/or P-glycoprotein (P-gp) inhibitors (HR 1.23; 95% CI 1.01–1.5). The use of inducers of CYP3A4 and/or P-gp was low in this cohort, and effects on ischemic stroke/TIA/stroke unspecified could not be established. Conclusion Increased risk of bleeding was seen for pharmacodynamic and pharmacokinetic interactions with NOACs. Prescribers need to be vigilant of the effect of interacting drugs on the risk profile of patients treated with NOACs.

scholarly journals Early Initiation of Direct Oral Anticoagulants After Onset of Stroke and Short- and Long-Term Outcomes of Patients With Nonvalvular Atrial Fibrillation

Stroke ◽  
2020 ◽  
Vol 51 (3) ◽  
pp. 883-891 ◽  
Author(s):  
Tadataka Mizoguchi ◽  
Kanta Tanaka ◽  
Kazunori Toyoda ◽  
Sohei Yoshimura ◽  
Ryo Itabashi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Hazard Ratio ◽  
Interquartile Range ◽  
Systemic Embolism ◽  
Nonvalvular Atrial Fibrillation ◽  
Ischemic Attack

Background and Purpose— We aimed to compare outcomes of ischemic stroke patients with nonvalvular atrial fibrillation between earlier and later initiation of direct oral anticoagulants (DOACs) after stroke onset. Methods— From data for 1192 nonvalvular atrial fibrillation patients with acute ischemic stroke or transient ischemic attack in a prospective, multicenter, observational study, patients who started DOACs during acute hospitalization were included and divided into 2 groups according to a median day of DOAC initiation after onset. Outcomes included stroke or systemic embolism, major bleeding, and death at 3 months, as well as those at 2 years. Results— DOACs were initiated during acute hospitalization in 499 patients in median 4 (interquartile range, 2–7) days after onset. Thus, 223 patients (median age, 74 [interquartile range, 68–81] years; 78 women) were assigned to the early group (≤3 days) and 276 patients (median age, 75 [interquartile range, 69–82] years; 101 women) to the late (≥4 days) group. The early group had lower baseline National Institutes of Health Stroke Scale score and smaller infarcts than the late group. The rate at which DOAC administration persisted at 2 years was 85.2% overall, excluding patients who died or were lost to follow-up. Multivariable Cox shared frailty models showed comparable hazards between the groups at 2 years for stroke or systemic embolism (hazard ratio, 0.86 [95% CI, 0.47–1.57]), major bleeding (hazard ratio, 1.39 [95% CI, 0.42–4.60]), and death (hazard ratio, 0.61 [95% CI, 0.28–1.33]). Outcome risks at 3 months also did not significantly differ between the groups. Conclusions— Risks for events including stroke or systemic embolism, major bleeding, and death were comparable whether DOACs were started within 3 days or from 4 days or more after the onset of nonvalvular atrial fibrillation–associated ischemic stroke or transient ischemic attack. Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT01581502.

scholarly journals Searching for Atrial Fibrillation Poststroke

Circulation ◽  
2019 ◽  
Vol 140 (22) ◽  
pp. 1834-1850 ◽  
Author(s):  
Renate B. Schnabel ◽  
Karl Georg Haeusler ◽  
Jeffrey S. Healey ◽  
Ben Freedman ◽  
Giuseppe Boriani ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Vitamin K ◽  
Transient Ischemic Attack ◽  
Embolic Stroke ◽  
Ecg Monitoring ◽  
Electrocardiographic Monitoring ◽  
Unknown Source ◽  
Increased Risk ◽  
Ischemic Attack

Cardiac thromboembolism attributed to atrial fibrillation (AF) is responsible for up to one-third of ischemic strokes. Stroke may be the first manifestation of previously undetected AF. Given the efficacy of oral anticoagulants in preventing AF-related ischemic strokes, strategies of searching for AF after a stroke using ECG monitoring followed by oral anticoagulation (OAC) treatment have been proposed to prevent recurrent cardioembolic strokes. This white paper by experts from the AF-SCREEN International Collaboration summarizes existing evidence and knowledge gaps on searching for AF after a stroke by using ECG monitoring. New AF can be detected by routine plus intensive ECG monitoring in approximately one-quarter of patients with ischemic stroke. It may be causal, a bystander, or neurogenically induced by the stroke. AF after a stroke is a risk factor for thromboembolism and a strong marker for atrial myopathy. After acute ischemic stroke, patients should undergo 72 hours of electrocardiographic monitoring to detect AF. The diagnosis requires an ECG of sufficient quality for confirmation by a health professional with ECG rhythm expertise. AF detection rate is a function of monitoring duration and quality of analysis, AF episode definition, interval from stroke to monitoring commencement, and patient characteristics including old age, certain ECG alterations, and stroke type. Markers of atrial myopathy (eg, imaging, atrial ectopy, natriuretic peptides) may increase AF yield from monitoring and could be used to guide patient selection for more intensive/prolonged poststroke ECG monitoring. Atrial myopathy without detected AF is not currently sufficient to initiate OAC. The concept of embolic stroke of unknown source is not proven to identify patients who have had a stroke benefitting from empiric OAC treatment. However, some embolic stroke of unknown source subgroups (eg, advanced age, atrial enlargement) might benefit more from non–vitamin K-dependent OAC therapy than aspirin. Fulfilling embolic stroke of unknown source criteria is an indication neither for empiric non–vitamin K-dependent OAC treatment nor for withholding prolonged ECG monitoring for AF. Clinically diagnosed AF after a stroke or a transient ischemic attack is associated with significantly increased risk of recurrent stroke or systemic embolism, in particular, with additional stroke risk factors, and requires OAC rather than antiplatelet therapy. The minimum subclinical AF duration required on ECG monitoring poststroke/transient ischemic attack to recommend OAC therapy is debated.

Left Atrial Size and Ischemic Events after Ischemic Stroke or Transient Ischemic Attack in Patients with Nonvalvular Atrial Fibrillation

2020 ◽  
Vol 49 (6) ◽  
pp. 619-624
Author(s):  
Keisuke Tokunaga ◽  
Masatoshi Koga ◽  
Sohei Yoshimura ◽  
Yasushi Okada ◽  
Hiroshi Yamagami ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Left Atrial ◽  
Nonvalvular Atrial Fibrillation ◽  
Ischemic Event ◽  
Increased Risk ◽  
Ischemic Attack ◽  
Ischemic Events

<b><i>Background:</i></b> The present study aimed to clarify the association between left atrial (LA) size and ischemic events after ischemic stroke or transient ischemic attack (TIA) in patients with nonvalvular atrial fibrillation (NVAF). <b><i>Methods:</i></b> Acute ischemic stroke or TIA patients with NVAF were enrolled. LA size was classified into normal LA size, mild LA enlargement (LAE), moderate LAE, and severe LAE. The ischemic event was defined as ischemic stroke, TIA, carotid endarterectomy, carotid artery stenting, acute coronary syndrome or percutaneous coronary intervention, systemic embolism, aortic aneurysm rupture or dissection, peripheral artery disease requiring hospitalization, or venous thromboembolism. <b><i>Results:</i></b> A total of 1,043 patients (mean age, 78 years; 450 women) including 1,002 ischemic stroke and 41 TIA were analyzed. Of these, 351 patients (34%) had normal LA size, 298 (29%) had mild LAE, 198 (19%) had moderate LAE, and the remaining 196 (19%) had severe LAE. The median follow-up duration was 2.0 years (interquartile range, 0.9–2.1). During follow-up, 117 patients (11%) developed at least one ischemic event. The incidence rate of total ischemic events increased with increasing LA size. Severe LAE was independently associated with increased risk of ischemic events compared with normal LA size (multivariable-adjusted hazard ratio, 1.75; 95% confidence interval, 1.02–3.00). <b><i>Conclusion:</i></b> Severe LAE was associated with increased risk of ischemic events after ischemic stroke or TIA in patients with NVAF.

scholarly journals MP37: Adherence to Canadian Cardiovascular Society guidelines for prescribing oral anticoagulants to patients with atrial fibrillation in the emergency department

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S55-S56
Author(s):  
D. Hung ◽  
M. Butler ◽  
S. Campbell
Keyword(s):  
Atrial Fibrillation ◽  
Emergency Department ◽  
Ischemic Stroke ◽  
Oral Anticoagulants ◽  
Previous History ◽  
Retrospective Chart Review ◽  
Prescribing Patterns ◽  
Prescribing Practices ◽  
Increased Risk ◽  
New Onset

Introduction: Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED) and is associated with an increased risk of ischemic stroke. Studies have shown that only oral anticoagulant (OAC) therapy reduces risk of AF related stroke. Our objective was to measure the prescribing practices for OACs for new onset AF at a tertiary ED and two surrounding community EDs, and identify rates of adverse effects within 90 days. The findings of this study will provide quality assurance information for the management of patients with new onset AF. This information has the potential to promote adherence to prescribing guidelines for AF in the ED and the reduction of common adverse events such as ischemic stroke. Methods: We conducted a retrospective chart review of 385 patients with new onset AF who presented to the ED between November 2014 to Mach 2018. We defined new onset as symptoms &lt;48 hours and had AF confirmed with electrocardiogram. We recorded the selected therapy choice of cardioversion and/or rate control, gender, age, and assessed CHADS-65 score. We recorded who was prescribed OAC and those who were referred to cardiology, family medicine, or did not have a documented follow up plan. Patients with a previous history of AF or current anticoagulant therapy were excluded. We recorded if any patients returned to the ED within 90 days with ischemic stroke, AF recurrence, myocardial infarction, other embolic disease or death. Results: 86 of 294 (29.5%) of patients who qualified under CHADS-65 received OACs appropriately. 64 of 66 (97.0%) of patients who did not qualify under CHADS-65 did not receive OACs appropriately. 5 patients overall returned within 90 days with ischemic stroke, 4 of those were not prescribed OACs, however this was not statistically significant (P = 0.999). Conclusion: This data suggests that physicians in the study are under-prescribing OACs relative to published guidelines. A larger study is necessary to elucidate the effect of ED OAC prescribing patterns on long-term patient outcome.

Transient atrial fibrillation and risk of stroke after acute myocardial infarction

2011 ◽  
Vol 106 (11) ◽  
pp. 877-884 ◽  
Author(s):  
Rema Bishara ◽  
Gregory Telman ◽  
Fadel Bahouth ◽  
Jonathan Lessick ◽  
Doron Aronson
Keyword(s):  
Myocardial Infarction ◽  
Atrial Fibrillation ◽  
Acute Myocardial Infarction ◽  
Ischaemic Stroke ◽  
Hospital Discharge ◽  
Oral Anticoagulants ◽  
Antiplatelet Agents ◽  
Increased Risk ◽  
One Year ◽  
The Impact

SummaryAtrial fibrillation (AF) is a frequent complication of acute myocardial infarction (AMI). In the AMI setting, AF is frequently brief and attributed to acute haemodynamic changes, inflammation or ischaemia. However, it remains uncertain whether transient AF episodes are associated with a subsequent increased risk of ischaemic stroke. We studied the impact of transient new-onset AF on the one-year risk of ischaemic stroke or transient ischaemic attack (TIA) in a retrospective cohort of 2,402 patients with AMI. Patients with previous AF or AF at hospital discharge were excluded. Transient AF occurred in 174 patients (7.2%) during the initial hospitalisation. During one year follow-up after hospital discharge, stroke or TIA occurred in 16 (9.2%) and 58 (2.6%) patients with and without transient AF, respectively (p< 0.0001). Compared with patients without transient AF, the adjusted hazard ratio for stroke or TIA in patients with transient AF was 3.03 (95% CI 1.73–5.32; p< 0.0001). Stroke or TIA occurred in 2.6% of patients without AF, 6.3% of patients with transient AF treated with oral anticoagulants, and 9.9% of patients with transient AF treated with antiplatelet agents. The incidence of recurrent AF after hospital discharge was markedly higher in patients with transient AF during the index hospitalisation (22.8% vs. 2.0%, p< 0.0001). In conclusion, transient AF complicating AMI is associated with an increased future risk of ischaemic stroke and TIA, particularly in patients treated with antiplatelet agents alone. High AF recurrence rates in these patients also suggest that oral anticoagulants should be strongly considered.

scholarly journals CHA2DS2-VASc score in acute ischemic stroke with atrial fibrillation: results from the Clinical Research Collaboration for Stroke in Korea

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Hak-Loh Lee ◽  
Joon-Tae Kim ◽  
Ji Sung Lee ◽  
Beom Joon Kim ◽  
Jong-Moo Park ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Primary Outcome ◽  
Research Collaboration ◽  
Recurrent Stroke ◽  
Oral Anticoagulants ◽  
Vascular Events ◽  
Stroke Registry ◽  
One Year

AbstractWe investigated a multicenter registry to identify estimated event rates according to CHA2DS2-VASc scores in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF). The additional effectiveness of antiplatelets (APs) plus oral anticoagulants (OACs) compared with OACs alone considering the CHA2DS2-VASc scores was also explored. This study retrospectively analyzed a multicenter stroke registry between Jan 2011 and Nov 2017, identifying patients with acute ischemic stroke with AF. The primary outcome event was a composite of recurrent stroke, myocardial infarction, and all-cause mortality within 1 year. A total of 7395 patients (age, 73 ± 10 years; men, 54.2%) were analyzed. The primary outcome events at one year ranged from 5.99% (95% CI 3.21–8.77) for a CHA2DS2-VASc score of 0 points to 30.45% (95% CI 24.93–35.97) for 7 or more points. After adjustments for covariates, 1-point increases in the CHA2DS2-VASc score consistently increased the risk of primary outcome events (aHR 1.10 [1.06–1.15]) at 1-year. Among OAC-treated patients at discharge (n = 5500), those treated with OAC + AP (vs. OAC alone) were more likely to experience vascular events, though among patients with a CHA2DS2-VASc score of 5 or higher, the risk of primary outcome in the OAC + AP group was comparable to that in the OAC alone group (Pint = 0.01). Our study found that there were significant associations of increasing CHA2DS2-VASc scores with the increasing risk of vascular events at 1-year in AIS with AF. Further study would be warranted.

scholarly journals Non-vitamin K oral anticoagulants (NOACs) in patients with stroke and atrial fibrillation

2020 ◽  
Vol 70 (5) ◽  
pp. 269-283
Author(s):  
Dejana Jovanović
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Vitamin K ◽  
Hemorrhagic Stroke ◽  
Small Vessel Disease ◽  
Oral Anticoagulants ◽  
Stroke Recurrence ◽  
Ischemic Attack

Patients with atrial fibrillation who had a previous transient ischemic attack or ischemic stroke had a significantly high risk of stroke recurrence and the introduction of oral anticoagulants should be mandatory. However, the long-term use of oral anticoagulants increases the risk of developing all types of intracranial hemorrhages. The advantages of non-vitamin K oral anticoagulants (NOACs) compared to warfarin are that they have a significantly lower risk for hemorrhagic stroke. They are preferred in elderly patients, those with small vessel disease, or those with previous intracerebral hemorrhage. The time of NOACs introduction after an ischemic stroke depends on its severity and the rule "1-3-6-12" days should be applied. The reintroduction of NOACs in patients with atrial fibrillation and previous intracerebral hemorrhage depends on its etiology and should be after about 4-8 weeks if the cardioembolic risk is high and the risk for intracranial hemorrhage small.

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