Abstract TP426: Factors Associated With Oral Anticoagulant Non-Use for Patients With Atrial Fibrillation-Related Stroke: The Florida Puerto Rico Atrial Fibrillation Stroke Study

Background: Oral anticoagulants (OACs) for stroke prevention in atrial fibrillation (AF) are largely underutilized. We identified pre-admission OAC utilization patterns and factors predictive of OAC non-use in patients hospitalized for AF-related stroke. Methods: We included 22,220 patients with ischemic stroke due to previously diagnosed AF enrolled in the Florida Stroke Registry from 2010-2017. A multivariable-adjusted logistic regression model was used to identify factors associated with pre-stroke OAC use for patients with AF-related stroke. Results: A total of 16,246 (73%) patients with AF-related stroke were not on OAC pre-stroke. Compared to patients on OAC, non-OAC patients were more likely to be ≥80 years old, have Medicaid/no insurance, lower CHA 2 DS 2 -VASc scores and greater stroke severity at presentation. After adjustment for age, sex, race-ethnicity, insurance status and vascular risk factors, baseline OAC non-use was higher for patients with Medicaid/no insurance (vs. private insurance, (OR 1.34 [95% CI 1.08-1.67]), smokers (OR 1.29 [1.09-1.52] and patients with NIHSS ≥6 (vs. NIHSS≤5, OR 1.18 [1.11-1.26]). A trend towards greater odds of OAC non-use was seen in women (vs. men, OR 1.07 [0.99-1.14, P=0.07]). Conclusion: The majority of AF-related stroke patients with known AF were not anticoagulated prior to hospitalization for stroke in our study. Insurance status and smoking status had the greatest influence on pre-stroke OAC use. Anticoagulated patients had lower stroke severity on admission. Further efforts are needed to increase OAC use to reduce the burden of stroke for patients with AF, especially for vulnerable populations.

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306 The Changing Face of Stroke in the DOAC Era

Age and Ageing ◽

10.1093/ageing/afz103.196 ◽

2019 ◽

Vol 48 (Supplement_3) ◽

pp. iii17-iii65

Author(s):

Recie Davern ◽

Helena Hobbs ◽

Hannah Murugan ◽

Paul Cotter

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulants ◽

P Value ◽

Stroke Management ◽

Medicines Management ◽

First Line ◽

Stroke Registry ◽

Multiple Factors ◽

Direct Acting ◽

Anticoagulated Patients

Abstract Background Patients prescribed oral anticoagulants (OAC) for atrial fibrillation (AF) can still present with stroke. The mechanism for stroke in these patients can be due to multiple factors including subtherapeutic dosing and non-compliance. With the increasing use of direct-acting OACs (DOACs) in favour of warfarin, it is unclear if the incidence of stroke in those already taking OAC has reduced. Methods Data was extracted from our unit’s stroke registry, a prospectively maintained database, for patients who presented with stroke while receiving OAC for AF from 2013 to 2017. Type of OAC, type of stroke, OAC dosing at time of event including non-compliance, stroke management and outcome were recorded. Results 67 patients were included for analysis, with 55 ischaemic and 12 haemorrhagic strokes. 52 patients were receiving warfarin at the time of their stroke vs. 15 receiving DOACs. 33/55 (60%) of ischaemic strokes occurred in patients taking warfarin with a sub-therapeutic INR. In 3/55 (5%) of ischaemic strokes, the OAC was held for a procedure while in 6/55 cases (11%) the OAC had been stopped for another reasons e.g. bleeding. 5/55 (7%) were due to non-compliance. 1 ischaemic stroke was due to under-dosing of a DOAC (dabigatran). 16 strokes were recorded in 2013 for patients prescribed OAC vs. 3 in 2017. Overall the number of ischaemic strokes due to subtherapeutic OAC decreased from 14 in 2013 to 1 in 2017 (p value 0.06). Conclusion The majority of strokes occurring in anticoagulated patients are related to warfarin use. We observed an almost significant reduction in the proportion of ischaemic strokes due to under-dosing of OAC over the study period. Warfarin continues to be recommended as the first line anticoagulant for stroke prevention in atrial fibrillation by the HSE Medicines Management Programme, a decision which we would argue warrants review.

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Underdosed Direct Oral Anticoagulants in Atrial Fibrillation Patients Reduce Stroke Severity and Improve Outcome

Cerebrovascular Diseases ◽

10.1159/000520857 ◽

2021 ◽

pp. 1-8

Author(s):

Masaki Naganuma ◽

Yuichiro Inatomi ◽

Toshiro Yonehara ◽

Makoto Nakajima ◽

Mitsuharu Ueda

Keyword(s):

Atrial Fibrillation ◽

Functional Outcomes ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

National Institutes Of Health ◽

Stroke Severity ◽

Anticoagulant Drugs ◽

Scale Scores ◽

Anticoagulant Drug ◽

Ischemic Attack

Background and Purpose: Anticoagulant drugs, including vitamin K antagonist (VKA) and direct oral anticoagulants (DOACs), can reduce stroke severity and are associated with good functional outcomes. Some patients are prescribed lower-than-recommended doses of DOACs; whether these have similar effects has not been clarified. Methods: We retrospectively evaluated 1,139 consecutive ischemic stroke and transient ischemic attack patients with atrial fibrillation. Patients were divided into 5 groups according to their preceding anticoagulant drug therapies: no anticoagulant therapy (ACn), undercontrolling VKA doses (VKAuc), recommended, controlling VKA doses (VKArec), prescribed underdoses of DOAC (DOACud), and recommended doses of DOAC (DOACrec). We investigated the associations between these anticoagulant drug therapies and patients’ initial stroke severity and 3-month outcomes. Results: Median National Institutes of Health Stroke Scale scores at admission were as follows: ACn: 16, VKAuc: 15, VKArec: 9, DOACud: 5, and DOACrec: 7. When the ACn group was used as a reference, regression analysis showed that VKArec (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.01–2.21), DOACud (OR 2.84, 95% CI: 1.47–5.66), and DOACrec (OR 1.83, 95% CI: 1.23–2.74) were associated with milder stroke severity, while VKAuc was not. Median 3-month modified Rankin Scale scores were 2 in the DOACud and DOACrec groups and 4 in all other groups. After adjusting for confounding factors, DOACud (OR 3.14, 95% CI: 1.50–6.57) and DOACrec (OR 1.67, 95% CI: 1.05–2.64) were associated with good 3-month outcomes while VKAuc and VKArec were not. Conclusions: In patients with atrial fibrillation, recommended doses and underdoses of DOACs reduced stroke severity on admission and were associated with good 3-month outcomes.

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Factors associated with non–vitamin K antagonist oral anticoagulants for stroke prevention in patients with new-onset atrial fibrillation: Results from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II (ORBIT-AF II)

American Heart Journal ◽

10.1016/j.ahj.2017.03.024 ◽

2017 ◽

Vol 189 ◽

pp. 40-47 ◽

Cited By ~ 28

Author(s):

Benjamin A. Steinberg ◽

Peter Shrader ◽

Laine Thomas ◽

Jack Ansell ◽

Gregg C. Fonarow ◽

...

Keyword(s):

Atrial Fibrillation ◽

Vitamin K ◽

Stroke Prevention ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Factors Associated ◽

Informed Treatment ◽

Onset Atrial Fibrillation ◽

New Onset

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Vitamin K Antagonists, Non–Vitamin K Antagonist Oral Anticoagulants, and Vascular Calcification in Patients with Atrial Fibrillation

TH Open ◽

10.1055/s-0038-1675578 ◽

2018 ◽

Vol 02 (04) ◽

pp. e391-e398 ◽

Cited By ~ 8

Author(s):

Frederique Peeters ◽

Elton Dudink ◽

Dorien Kimenai ◽

Bob Weijs ◽

Sibel Altintas ◽

...

Keyword(s):

Atrial Fibrillation ◽

Logistic Regression ◽

Aortic Valve ◽

Propensity Score ◽

Vascular Calcification ◽

Vitamin K ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Vitamin K Antagonist ◽

Adjusted Logistic Regression

Background Vitamin K antagonists (VKAs) are associated with coronary artery calcification in low-risk populations, but their effect on calcification of large arteries remains uncertain. The effect of non–vitamin K antagonist oral anticoagulants (NOACs) on vascular calcification is unknown. We investigated the influence of use of VKA and NOAC on calcification of the aorta and aortic valve. Methods In patients with atrial fibrillation without a history of major adverse cardiac or cerebrovascular events who underwent computed tomographic angiography, the presence of ascending aorta calcification (AsAC), descending aorta calcification (DAC), and aortic valve calcification (AVC) was determined. Confounders for VKA/NOAC treatment were identified and propensity score adjusted logistic regression explored the association between treatment and calcification (Agatston score > 0). AsAC, DAC, and AVC differences were assessed in propensity score–matched groups. Results Of 236 patients (33% female, age: 58 ± 9 years), 71 (30%) used VKA (median duration: 122 weeks) and 79 (34%) used NOAC (median duration: 16 weeks). Propensity score–adjusted logistic regression revealed that use of VKA was significantly associated with AsAC (odds ratio [OR]: 2.31; 95% confidence interval [CI]: 1.16–4.59; p = 0.017) and DAC (OR: 2.38; 95% CI: 1.22–4.67; p = 0.012) and a trend in AVC (OR: 1.92; 95% CI: 0.98–3.80; p = 0.059) compared with non-anticoagulation. This association was absent in NOAC versus non-anticoagulant (AsAC OR: 0.51; 95% CI: 0.21–1.21; p = 0.127; DAC OR: 0.80; 95% CI: 0.36–1.76; p = 0.577; AVC OR: 0.62; 95% CI: 0.27–1.40; p = 0.248). A total of 178 patients were propensity score matched in three pairwise comparisons. Again, use of VKA was associated with DAC (p = 0.043) and a trend toward more AsAC (p = 0.059), while use of NOAC was not (AsAC p = 0.264; DAC p = 0.154; AVC p = 0.280). Conclusion This cross-sectional study shows that use of VKA seems to contribute to vascular calcification. The calcification effect was not observed in NOAC users.

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Stroke Patients with Atrial Fibrillation Treated with Oral Anticoagulants: Comparison of the Population-Based Stroke Registry of Dijon and the French National Health Databases

Neuroepidemiology ◽

10.1159/000511206 ◽

2020 ◽

Vol 54 (6) ◽

pp. 506-512

Author(s):

Amélie Gabet ◽

Valérie Olié ◽

Yannick Béjot

Keyword(s):

Atrial Fibrillation ◽

National Health ◽

Oral Anticoagulants ◽

Population Based ◽

Stroke Patients ◽

Stroke Registry ◽

Health Database ◽

Administrative Health Databases ◽

Almost All ◽

The City

Introduction: The objective of this study was to evaluate the complementarity of the French national health database (Système national des données de Santé, SNDS) and the Dijon Stroke Registry for the epidemiology of stroke patients with anticoagulated atrial fibrillation (AF). Methods: The SNDS collects healthcare prescriptions and procedures reimbursed by the French national health insurance for almost all of the 66 million individuals living in France. A previously published algorithm was used to identify AF newly treated with oral anticoagulants. The Dijon Stroke Registry is a population-based study covering the residents of the city of Dijon since 1985 and records all stroke cases of the area. We compared the proportions of stroke patients with anticoagulated AF in the city of Dijon identified in SNDS databases to those registered in the Dijon Stroke Registry. Results: For the period 2013–2017 in the city of Dijon, 1,146 strokes were identified in the SNDS and 1,188 in the registry. The proportion of strokes with anticoagulated AF was 13.4% in the SNDS and 20.3% in the Dijon Stroke Registry. Very similar characteristics were found between patients identified through the 2 databases. The overall prevalence of AF in stroke patients could be estimated only in the Dijon stroke registry and was 30.4% for the study period. Discussion/Conclusion: If administrative health databases can be a useful tool to study the epidemiology of anticoagulated AF in stroke patients, population-based stroke registries as the Dijon Stroke Registry remain essential to fully study the epidemiology of strokes with anticoagulated AF.

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Persistent or permanent atrial fibrillation is associated with severe cardioembolic stroke in patients with non-valvular atrial fibrillation

Thrombosis Journal ◽

10.1186/s12959-021-00276-9 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Joji Hagii ◽

Norifumi Metoki ◽

Shin Saito ◽

Hiroshi Shiroto ◽

Satoko Sasaki ◽

...

Keyword(s):

Atrial Fibrillation ◽

Functional Outcome ◽

Oral Anticoagulants ◽

Japanese Patients ◽

Artery Occlusion ◽

Carotid Artery Occlusion ◽

Stroke Severity ◽

Group 13 ◽

Severe Stroke ◽

The Difference

Abstract Background Little is known about the difference in the severity of cardioembolic (CE) stroke between patients with paroxysmal atrial fibrillation (PAF) and persistent/permanent AF (PerAF). We assessed stroke severity in patients with CE stroke divided by the type of AF. Methods Three hundred and fifty-eight consecutive patients with CE stroke within 48 h of onset and with a modified Rankin Scale (mRS) score ≤ 1 before onset were studied. We compared basic characteristics, stroke severity, and functional outcome between patients with PAF (n = 127) and PerAF (n = 231). Results Patients with PerAF were more likely to take oral anticoagulants (OACs) than those with PAF (37% vs. 13%, P < 0.0001), even though still underuse of OAC in both patients. Regarding stroke severity on admission, patients with PerAF exhibited a tendency toward a higher score on the National Institutes of Health Stroke Scale (NIHSS) compared with patients with PAF (12 [5–20] vs. 9 [4–18]; P = 0.12). Mortality and mRS score at discharge were higher in the PerAF than in the PAF group (13% vs. 4%; P = 0.005, and 3 [1–5] vs. 2 [1–4]; P = 0.01, respectively). Multivariate analyses confirmed that PerAF was a significant determinant of severe stroke (NIHSS score > 8) on admission (odds ratio [OR] to PAF = 1.80; 95% confidence interval [CI] 1.08–2.98; P = 0.02) and of an mRS score ≥ 3 at discharge (OR = 2.07; 95% CI 1.24–3.46; P = 0.006). Patients with PerAF had three times more internal carotid artery occlusion evaluated by magnetic resonance angiography, which indicated a more severe cerebral embolism compared with patients with PAF. Conclusions We found underuse of OAC in high risk AF patients with CE stroke. PerAF is significantly associated with severe stroke on admission and an unfavorable functional outcome at discharge in Japanese patients with CE stroke.

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

European Heart Journal ◽

10.1093/ehjci/ehaa946.0522 ◽

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

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Factors associated with inappropriate reduced doses of non-vita-min K antagonist oral anticoagulants in patients with atrial fibrillation

The Scientific Notes of the I P Pavlov St Petersburg State Medical University ◽

10.24884/1607-4181-2021-28-1-52-61 ◽

2021 ◽

Vol 28 (1) ◽

pp. 52-61

Author(s):

V. A. Ionin ◽

O. I. Bliznuk ◽

V. A. Pavlova ◽

E. I. Baranova

Keyword(s):

Atrial Fibrillation ◽

Dabigatran Etexilate ◽

Oral Anticoagulants ◽

Bleeding Risk ◽

Case Histories ◽

Prehospital Treatment ◽

Factors Associated ◽

The Past ◽

Outpatient Practice ◽

The University

The objective was to study the factors associated with inappropriate reduced doses of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation (AF) in real outpatient practice.Methods and materials. 10663 case histories of patients hospitalized to the therapeutic clinic of the university for 5 years (2014 — 2018) were studied, 1307/10663 (12,3 %) case histories of patients with AF were selected. Factors associated with inappropriate low doses of anticoagulant therapy (ACT) with NOACs at prehospital treatment were studied.Results. NOACs received 57.7 % (384/665) of patients with AF at the outpatient stage: rivaroxaban — 180/384 (46.9 %) patients, dabigatran etexilate — 110/384 (28.6 %) patients, apixaban — 94/384 (24.5 %) patients. Inappropriate reduced doses of NOACs were revealed in 68/384 (17.7 %) patients: apixaban — 22/94 (23.4 %), dabigatran — 18/110 (16,4 %) and rivaroxaban — 28/180 (15.6 %) (p>0,05). Patients who received inappropriate reduced doses of NOACs as compared to those who received standard doses of NOACs had higher frequency of major bleedings in the past (7.4 and 1.0 %; p=0.014) and had higher risk of bleedings (HAS-BLED 1.7±1,1 and 1.2±1.0; p = 0.0002). Proportion of patients who had HAS-BLED≥3 in these groups were 19.1 % and 8.6 % (p=0.033). All patients who received inappropriate reduced doses of NOACs had modifiable risk factors of bleedings. 85.3 % of patients with AF who received inappropriate reduced doses of NOACs had high risk of stroke according to CHA2DS2-VASc scale.Conclusion. In real outpatient practice, NOACs were recommended to 57.7 % of patients with AF. 17.7 % of patients received NOACs s in inappropriate reduced doses. Frequency of major bleedings in the past and bleeding risk in AF patients with inappropriate reduced doses was higher than in patients with standard doses.

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

Scientific Reports ◽

10.1038/s41598-020-80874-1 ◽

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.

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Ischemic Stroke With Atrial Fibrillation

Stroke ◽

10.1161/strokeaha.120.030812 ◽

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.

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