Impact of prescription patterns of antithrombotic treatment on atrial fibrillation-related ischemic stroke

Freixa-Pamias, Román; Blanch, Pedro; Latre, Maria Lluïsa Rodríguez; Basile, Luca; Chamero, Pilar Sánchez; Gómez-Choco, Manuel; Armario, Pedro; Martínez‐Rubio, Antoni; Lupón, Josep

doi:10.1080/03007995.2020.1865892

“…Very similar to our findings, the study by Freixa-Pamias et al 3 reflects the transition from vitamin-K antagonists (VKAs)…”

Section: Potential Conflict Of Interestsupporting

confidence: 93%

Prior anticoagulation in patients with ischemic stroke and atrial fibrillation

Kawada

¹

2021

Annals of Neurology

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colleagues 1 reported the effect of prior anticoagulation with vitamin K antagonists or direct oral anticoagulants (DOACs) on subsequent stroke severity, utilization of intravenous thrombolysis (IVT), safety of IVT, and 3-month outcomes in patients with ischemic stroke and atrial fibrillation (AF). Prior DOAC therapy was significantly associated with decreased admission stroke severity and a lower rate of IVT. In addition, the adjusted odds ratio (OR; 95% confidence interval [CI]) of DOAC pretreatment for a favorable 3-month outcome was 1.24 (95% CI = 1.01-1.51). I have some concerns on their study.First, Jung and colleagues 2 conducted a prospective study to investigate the preceding antithrombotic medication use in patients with AF with acute ischemic stroke and its association with initial stroke severity and in-hospital outcomes. The OR (95% CI) of antiplatelet and anticoagulant users for a mild initial neurological deficit were 1.23 (95% CI = 1.09-1.38) and 1.31 (95% CI = 1.15-1.50), respectively. As a large portion of patients with AF still did not receive antithrombotic medication before an ischemic stroke event, they recommended prehospitalization use of antithrombotic medication to keep a mild initial neurological deficit and favorable outcome at discharge. I think that subanalysis by classifying anticoagulants into vitamin K antagonists and DOACs might lead to the advantage of DOACs for keeping safety and effectiveness on clinical outcomes.Second, Freixa-Pamias and colleagues 3 conducted a retrospective study to evaluate the association of AF-related ischemic stroke with the prescription patterns of antithrombotic treatment. The adjusted OR (95% CI) of patients with antiplatelet versus control medications with vitamin K antagonists or DOACs for ischemic stroke was 1.89 (95% CI = 1.52-2.37), and risk reduction for ischemic stroke by vitamin K antagonists or DOACs treatment was remarkable. To specify the superiority between vitamin K antagonists and DOACs, an intervention study is recommended.Finally, Kimura and colleagues 4 conducted a prospective study to evaluate safety and effectiveness of oral anticoagulants (OACs) for preventing secondary ischemic stroke in patients with ischemic stroke and AF. As the risk of acute recurrence of ischemic stroke was high in patients with AF, they recommended OAC treatment as early as possible. The OACs include vitamin K antagonists and DOACs. Chan and colleagues 5 conducted a meta-analysis and DOACs had greater effectiveness and safety compared to vitamin K antagonists for stroke prevention in patients with AF. Regarding safety, Kattoor and colleagues 6 reported that the risk of gastrointestinal bleeding and stroke was similar between vitamin K antagonist and DOAC users, and there was a trend toward lower intracranial hemorrhage in the DOAC users. In any case, standard treatment protocol by DOACs should be presented by considering comorbidity and hemorrhagic risk in each individual.

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“…4,5 The increased uptake of OACs prompted by the introduction of DOACs has been associated with a decrease in the risk of stroke among patients with AF. [4][5][6][7][8][9][10][11][12][13] This evolution of increasing usage of OACs and decreasing risk of stroke has been reported in several countries, including the United States, 4 Denmark, 5 England, 10 Sweden, 6 Germany, 7 Korea, 8 Italy, 9 and Japan. 11 Denmark, Sweden, and Finland have national administrative registries holding information about hospitalizations, medical treatment, and mortality, which provide unique opportunities for examining international and intranational variations in the initiation of OAC in the entire population of patients with a hospital diagnosis of AF.…”

Section: Introductionmentioning

confidence: 88%

Geographical Variation in the Use of Oral Anticoagulation and Clinical Outcomes among Patients with Atrial Fibrillation in Denmark, Sweden, and Finland

Frost

¹

,

Halminen

²

,

Lehto

³

et al. 2023

TH Open

2

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Background Geographical mapping of variations in the treatment and outcomes of a disease is a valuable tool for identifying inequity. We examined international and intranational variations in initiating oral anticoagulation (OAC) therapy and clinical outcomes among patients with atrial fibrillation (AF) in Nordic countries. We also tracked real-world trends in initiating OAC and the clinical outcomes. Methods We conducted a registry-based multinational cohort study of OAC-naïve patients with an incident hospital diagnosis of AF in Denmark (N=61,345), Sweden (N=124,120), and Finland (N=59,855) and a CHA2DS2-VASc score of ≥1 in men and ≥2 in women between 2012 and 2017. Initiation of OAC therapy was defined as dispensing at least one prescription between 90 days before and 90 days after the AF diagnosis. Clinical outcomes included ischaemic stroke, intracerebral haemorrhage, intracranial bleeding, other major bleeding, and all-cause mortality. Results The proportion of patients initiating OAC therapy ranged from 67.7% (95% CI: 67.5-68.0) in Sweden to 69.6% (95% CI: 69.2-70.0) in Finland, with intranational variation. The 1-year risk of stroke varied from 1.9% (95% CI: 1.8-2.0) in Sweden and Finland to 2.3% (95% CI: 2.2-2.4) in Denmark, with intranational variation. The initiation of OAC therapy increased with a preference for direct oral anticoagulants over warfarin. The risk of ischaemic stroke decreased with no increase in intracranial and intracerebral bleeding. Conclusion We documented inter- and intranational variation in initiating OAC therapy and clinical outcomes across Nordic countries. Adherence to structured care of patients with AF could reduce future variation.

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“…2 Additionally, other studies who have evaluated different factors that influence the success of endovascular therapy reported that the start time of this therapy was shorter between 20:55-22:57 and 22:57-02:07 hours (p = 0.004). 3 It was also evidenced that endovascular therapies performed in the morning between 08:00-10:20 (OR 0.53; p < 0.001) and 10:20-11:40 (OR 0.62; p = 0.006), are associated with a better long-term outcome. 3 On the other hand, a study has associated the change in the summertime and its interference in the treatment with thrombolysis, showing an increase in the number of thrombolysis treatments in spring and autumn on the day and the week after the time change in comparison with the day and week before the time change, which may be related to the effects on the biorhythm that appear with the time change and sunlight conditions.…”

Section: Potential Conflicts Of Interestmentioning

confidence: 95%

“…3 It was also evidenced that endovascular therapies performed in the morning between 08:00-10:20 (OR 0.53; p < 0.001) and 10:20-11:40 (OR 0.62; p = 0.006), are associated with a better long-term outcome. 3 On the other hand, a study has associated the change in the summertime and its interference in the treatment with thrombolysis, showing an increase in the number of thrombolysis treatments in spring and autumn on the day and the week after the time change in comparison with the day and week before the time change, which may be related to the effects on the biorhythm that appear with the time change and sunlight conditions. 4 Based on the previous arguments, we strongly believe that at the time of treating for stroke patients, especially in those who we decide to perform bridging therapy, the current evidence can help us to strengthen our work teams to take into account those conditions that may affect the success of the treatment, such as…”

Section: Potential Conflicts Of Interestmentioning

confidence: 95%

Reply to “Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation”

Meinel

¹

,

Seiffge

²

2021

Annals of Neurology

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colleagues 1 reported the effect of prior anticoagulation with vitamin K antagonists or direct oral anticoagulants (DOACs) on subsequent stroke severity, utilization of intravenous thrombolysis (IVT), safety of IVT, and 3-month outcomes in patients with ischemic stroke and atrial fibrillation (AF). Prior DOAC therapy was significantly associated with decreased admission stroke severity and a lower rate of IVT. In addition, the adjusted odds ratio (OR; 95% confidence interval [CI]) of DOAC pretreatment for a favorable 3-month outcome was 1.24 (95% CI = 1.01-1.51). I have some concerns on their study.First, Jung and colleagues 2 conducted a prospective study to investigate the preceding antithrombotic medication use in patients with AF with acute ischemic stroke and its association with initial stroke severity and in-hospital outcomes. The OR (95% CI) of antiplatelet and anticoagulant users for a mild initial neurological deficit were 1.23 (95% CI = 1.09-1.38) and 1.31 (95% CI = 1.15-1.50), respectively. As a large portion of patients with AF still did not receive antithrombotic medication before an ischemic stroke event, they recommended prehospitalization use of antithrombotic medication to keep a mild initial neurological deficit and favorable outcome at discharge. I think that subanalysis by classifying anticoagulants into vitamin K antagonists and DOACs might lead to the advantage of DOACs for keeping safety and effectiveness on clinical outcomes.Second, Freixa-Pamias and colleagues 3 conducted a retrospective study to evaluate the association of AF-related ischemic stroke with the prescription patterns of antithrombotic treatment. The adjusted OR (95% CI) of patients with antiplatelet versus control medications with vitamin K antagonists or DOACs for ischemic stroke was 1.89 (95% CI = 1.52-2.37), and risk reduction for ischemic stroke by vitamin K antagonists or DOACs treatment was remarkable. To specify the superiority between vitamin K antagonists and DOACs, an intervention study is recommended.Finally, Kimura and colleagues 4 conducted a prospective study to evaluate safety and effectiveness of oral anticoagulants (OACs) for preventing secondary ischemic stroke in patients with ischemic stroke and AF. As the risk of acute recurrence of ischemic stroke was high in patients with AF, they recommended OAC treatment as early as possible. The OACs include vitamin K antagonists and DOACs. Chan and colleagues 5 conducted a meta-analysis and DOACs had greater effectiveness and safety compared to vitamin K antagonists for stroke prevention in patients with AF. Regarding safety, Kattoor and colleagues 6 reported that the risk of gastrointestinal bleeding and stroke was similar between vitamin K antagonist and DOAC users, and there was a trend toward lower intracranial hemorrhage in the DOAC users. In any case, standard treatment protocol by DOACs should be presented by considering comorbidity and hemorrhagic risk in each individual.

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Impact of prescription patterns of antithrombotic treatment on atrial fibrillation-related ischemic stroke

Cited by 6 publications

References 49 publications

Prior anticoagulation in patients with ischemic stroke and atrial fibrillation

Prior anticoagulation in patients with ischemic stroke and atrial fibrillation

Geographical Variation in the Use of Oral Anticoagulation and Clinical Outcomes among Patients with Atrial Fibrillation in Denmark, Sweden, and Finland

Reply to “Prior Anticoagulation in Patients with Ischemic Stroke and Atrial Fibrillation”

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