scholarly journals Real-World Management and Clinical Outcomes of Stroke Survivors With Atrial Fibrillation: A Population-Based Cohort in Spain

2021 ◽  
Vol 12 ◽  
Author(s):  
Clara L. Rodríguez-Bernal ◽  
Francisco Sanchez-Saez ◽  
Daniel Bejarano-Quisoboni ◽  
Judit Riera-Arnau ◽  
Gabriel Sanfélix-Gimeno ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Outcomes ◽  
Real World ◽  
Large Population ◽  
Temporal Trends ◽  
Population Based ◽  
Stroke Survivors ◽  
Gi Bleeding ◽  
Management Pattern ◽  
Time To Treatment

Objective: Despite the continuous update of clinical guidelines, little is known about the real-world management of patients with atrial fibrillation (AF) who survived a stroke. We aimed to assess patterns of therapeutic management of stroke survivors with AF and clinical outcomes using data from routine practice in a large population-based cohort.Methods: A population-based retrospective cohort study of all patients with AF who survived a stroke, from January 2010 to December 2017 in the Valencia region, Spain (n = 10,986), was carried out. Treatment strategies and mean time to treatment initiation are described. Temporal trends are shown by the management pattern during the study period. Factors associated with each pattern (including no treatment) vs. oral anticoagulant (OAC) treatment were identified using logistic multivariate regression models. Incidence rates of clinical outcomes (mortality, stroke/TIA, GI bleeding, and ACS) were also estimated by the management pattern.Results: Among stroke survivors with AF, 6% were non-treated, 23% were prescribed antiplatelets (APT), 54% were prescribed OAC, and 17% received OAC + APT at discharge. Time to treatment was 8.0 days (CI 7.6–8.4) for APT, 9.86 (CI 9.52–10.19) for OAC, and 16.47 (CI 15.86–17.09) for OAC + APT. Regarding temporal trends, management with OAC increased by 20%, with a decrease of 50% for APT during the study period. No treatment and OAC + APT remained relatively stable. The strongest predictor of no treatment and APT treatment was having the same management strategy pre-stroke. Those treated with APT had the highest rates of GI bleeding and recurrent stroke/TIA, and untreated patients showed the highest rates of mortality.Conclusion: In this large population-based cohort using real-world data, nearly 30% of AF patients who suffered a stroke were untreated or treated with APT, which overall is not recommended. Treatment was started within 2 weeks as recommended, except for OAC + APT, which was started later. The strong association of APT treatment or non-treatment with the same treatment strategy before stroke occurrence suggests a strong therapeutic inertia and opposes recommendations. Patients under these two strategies had the highest rates of adverse outcomes. An inadequate prescription poses a great risk on patients with AF and stroke; thus monitoring their management is necessary and should be setting-specific.

Abstract P005: Comparative Effectiveness of Rivaroxaban versus Warfarin for the Treatment of Patients with Non-valvular Atrial Fibrillation

Circulation ◽  
2016 ◽  
Vol 133 (suppl_1) ◽  
Author(s):  
Faye L Norby ◽  
Lindsay G Bengtson ◽  
Lin Y Chen ◽  
Richard F MacLehose ◽  
Pamela L Lutsey ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Real World ◽  
Proportional Hazards ◽  
Large Population ◽  
Population Based ◽  
Cox Proportional Hazards ◽  
Gi Bleeding ◽  
Cox Proportional Hazards Models ◽  
The Us

Background: Rivaroxaban is a novel oral anticoagulant approved in the US in 2011 for prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). Information on risks and benefits among rivaroxaban users in real-world populations is limited. Methods: We used data from the US MarketScan Commercial and Medicare Supplemental databases between 2010 and 2013. We selected patients with a history of NVAF and initiating rivaroxaban or warfarin. Rivaroxaban users were matched with up to 5 warfarin users by age, sex, database enrollment date and drug initiation date. Ischemic stroke, intracranial bleeding (ICB), myocardial infarction (MI), and gastrointestinal (GI) bleeding outcomes were defined by ICD-9-CM codes in an inpatient claim after drug initiation date. Cox proportional hazards models were used to assess the association between rivaroxaban vs. warfarin use and outcomes adjusting for age, sex, and CHA2DS2-VASc score. Separate models were used to compare a) new rivaroxaban users with new warfarin users, and b) switchers from warfarin to rivaroxaban to continuous warfarin users. Results: Our analysis included 34,998 rivaroxaban users matched to 102,480 warfarin users with NVAF (39% female, mean age 71), in which 487 ischemic strokes, 179 ICB, 647 MI, and 1353 GI bleeds were identified during a mean follow-up of 9 months. Associations of rivaroxaban vs warfarin were similar in new users and switchers; therefore we pooled both analyses. Rivaroxaban users had lower rates of ICB (hazard ratio (HR) (95% confidence interval (CI)) = 0.72 (0.46, 1.12))) and ischemic stroke (HR (95% CI) = 0.88 (0.68, 1.13)), but higher rates of GI bleeding (HR (95% CI) = 1.15 (1.01, 1.33)) when compared to warfarin users (table). Conclusion: In this large population-based study of NVAF patients, rivaroxaban users had a non-significant lower risk of ICB and ischemic stroke than warfarin users, but a higher risk of GI bleeding. These real-world findings are comparable to results reported in published clinical trials.

Abstract W MP66: Rates of Ischemic Stroke after Intracranial Hemorrhage in a Population-Based Sample of Patients with Atrial Fibrillation

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Michael P Lerario ◽  
Gino Gialdini ◽  
Daniel Lapidus ◽  
Mesha Shaw ◽  
Babak Navi ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Intracranial Hemorrhage ◽  
Anticoagulant Therapy ◽  
Stroke Risk ◽  
Hazard Analysis ◽  
Large Population ◽  
Population Based ◽  
Administrative Claims ◽  
Index Visit

Introduction: Patients with atrial fibrillation (AF) who experience intracranial hemorrhage (ICH) often cannot tolerate anticoagulant therapy and presumably face a higher risk of thromboembolism. However, there are little population-based data on long-term rates of stroke after ICH in patients with AF. Methods: Using validated diagnosis codes and administrative claims data from all nonfederal acute care hospitals and emergency departments in California, Florida, and New York from 2005 to 2012, we identified patients at their first encounter with a recorded diagnosis of AF. We excluded patients with diagnoses of stroke or ICH prior to their index visit or a diagnosis of stroke at the index visit. A time-varying covariate was used to account for ICH (intracerebral or subarachnoid hemorrhage) at the index visit or during follow-up. Kaplan-Meier survival statistics were used to calculate cumulative rates of stroke, and Cox proportional hazard analysis was used to evaluate the relationship between incident ICH and stroke while adjusting for the CHA 2 DS 2 VASc score. Results: During a mean 3.2 years of follow-up among 2,376,207 patients with AF, 25,243 (1.06%) developed ICH and 93,183 (3.92%) developed stroke. The cumulative 1-year rate of stroke was 6.50% (95% CI, 6.06-6.96%) after ICH versus 2.22% (95% CI, 2.20-2.24) in those without ICH. ICH remained associated with higher stroke risk after adjusting for the CHA 2 DS 2 VASc score (HR, 2.29; 95% CI, 2.18-2.40). Among patients with ICH, stroke risk rose in step with the CHA 2 DS 2 VASc score. Conclusions: In a large population-based cohort, patients with AF faced a substantially higher risk of stroke after ICH. This risk rose proportionally with increasing CHA 2 DS 2 VASc score. These findings point to patients with AF and ICH as a vulnerable population who may especially benefit from therapeutic alternatives to anticoagulant therapy for preventing thromboembolism in AF.

Atrial fibrillation detected at screening is not a benign condition - a comparison of clinical outcomes in screen-detected vs. hospital-detected atrial fibrillation

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
VW Zwartkruis ◽  
B Geelhoed ◽  
N Suthahar ◽  
RT Gansevoort ◽  
SJL Bakker ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Clinical Outcomes ◽  
Cox Regression ◽  
Population Based ◽  
Adverse Outcomes ◽  
Albumin Concentration ◽  
Benign Condition ◽  
National Budget ◽  
History Of ◽  
Time Varying Covariates

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Dutch Heart Foundation Background Screening for atrial fibrillation (AF) improves detection of AF. However, it is unknown whether AF detected at screening carries risks similar to clinically detected AF, and if it should be treated similarly. Purpose We aimed to compare clinical outcomes in individuals with screen-detected vs. hospital-detected incident AF. Methods We studied 8265 individuals (mean age 49 ± 13 years, 50% women) without prevalent AF from the population-based PREVEND (Prevention of Renal and Vascular End-Stage Disease) cohort study. By design, 70% of PREVEND participants had urinary albumin concentration ≥10 mg/l. AF was considered screen-detected when first detected on a 12-lead electrocardiogram (ECG) during one of the PREVEND study visits, and hospital-detected when first detected on a hospital ECG. Using Cox regression models with screen-detected and hospital-detected AF as time-varying covariates, we studied the association of screen-detected vs. hospital-detected AF with mortality, incident heart failure (HF), and incident cardiovascular (CV) events. Results During a mean follow-up of 9.7 years, 265 participants (3.2%) developed incident AF (mean age 62 ± 9 years, 30% women, 65% hypertension, 23% obesity, 9% diabetes, 15% history of myocardial infarction, 3% history of stroke, 2% prevalent HF). Of all incident AF cases, 60 (23%) were screen-detected and 205 (77%) hospital-detected. Baseline characteristics were generally comparable between participants with screen-detected and hospital-detected AF. A larger proportion of incident AF was screen-detected in men (26%) compared to women (15%). In univariabe analysis, both screen-detected and hospital-detected AF were strongly associated with death, incident HF, and incident CV events. After multivariable adjustment, hospital-detected AF was significantly associated with death (HR 2.95, 95% CI 2.18-4.00), incident HF (HR 3.98, 95% CI 2.49-6.34), and incident CV events (HR 1.92, 95% CI 1.21-3.06). Screen-detected AF was significantly associated with death (HR 2.21, 95% CI 1.09-4.47) and incident HF (HR 4.90, 95% CI 2.28-10.57), but not with incident CV events (HR 1.12, 95% CI 0.46-2.71). Conclusions In a population-based cohort enriched for microalbuminuria, almost a quarter of incident AF cases was first detected through ECG screening. Compared to hospital-detected AF, screen-detected AF was similarly associated with adverse outcomes. Although randomised trials are needed, this study highlights that AF screening may help decrease the general burden of CV disease.

Improved Population-Based Clinical Outcomes of Patients with Atrial Fibrillation by Compliance with the Simple ABC (Atrial Fibrillation Better Care) Pathway for Integrated Care Management: A Nationwide Cohort Study

2019 ◽  
Vol 119 (10) ◽  
pp. 1695-1703 ◽  
Author(s):  
Minjae Yoon ◽  
Pil-Sung Yang ◽  
Eunsun Jang ◽  
Hee Tae Yu ◽  
Tae-Hoon Kim ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Integrated Care ◽  
Clinical Outcomes ◽  
Care Management ◽  
Care Pathway ◽  
Holistic Approach ◽  
Population Based ◽  
Composite Outcome ◽  
Care Approach ◽  
Multivariable Regression

Background An integrated care approach might be of benefit for clinical outcomes of patients with atrial fibrillation (AF). This study evaluated whether compliance with the Atrial fibrillation Better Care (ABC) pathway for integrated care management (“A” Avoid stroke; “B” Better symptom management; “C” Cardiovascular risk and Comorbidity optimization) would improve population-based clinical outcomes in a nationwide AF cohort. Methods and Results From the Korea National Health Insurance Service database, a total of 204,842 nonvalvular AF patients were enrolled between January 1, 2005 and December 31, 2015. Patients that fulfilled all criteria of the ABC pathway were defined as the “ABC” group, and those who did not were the “Non-ABC” group.Over a mean follow-up of 6.2 ± 3.5 years, the ABC pathway compliant group had lower rates of all-cause death (0.80 vs. 2.72 per 100 person-years, p < 0.001) and the composite outcome of “death, ischemic stroke, major bleeding, and myocardial infarction” (2.34 vs. 5.92 per 100 person-years, p < 0.001) compared with the Non-ABC compliant group. Adjusted Cox multivariable regression showed that the ABC group had a significantly lower risk of all-cause death (adjusted hazard ratio [HR] 0.82; 95% confidence interval [CI], 0.78–0.86) and the composite outcome (adjusted HR 0.86; 95% CI, 0.83–0.89). With the increasing numbers of ABC pathway criteria fulfilled, the risk of all-cause death and composite outcome were progressively lowered. Conclusion In the first study of a nationwide population cohort, we show that compliance with the simple ABC pathway is associated with improved clinically relevant outcomes of patients with AF. Given the high health care burden associated with AF, such a streamlined holistic approach to AF management should be implemented, to improve the care of such patients.

Sign in / Sign up

Export Citation Format

Share Document