Modification of In-Hospital Recommendation and Prescription of Anticoagulants for Secondary Prevention of Stroke after Launch of Direct Oral Anticoagulants and Change of National Guidelines

Abstract

Introduction: Approximately 1 out of 4 stroke patients suffers ischemic stroke secondary to atrial fibrillation (AF). Although indicated, withholding of anticoagulants for secondary prevention is a widespread phenomenon. Objective: We examined the longitudinal change of recommendation and prescription of secondary preventive anticoagulation in AF patients in an acute stroke center setting focusing on the impact of the introduction of direct oral anticoagulants (DOACs) and the change of national stroke prevention guidelines. Methods: Consecutive patients admitted with an acute cerebrovascular ischemic event underwent regular diagnostic work-up. Pseudonymized clinical data were entered into the institution's stroke registry. In those patients with AF, discharge letters were collected and evaluated for temporal trends and affecting factors of recommended and prescribed antithrombotic secondary medication at the time of discharge from hospital. Results: Of 7,175 patients admitted between January 2009 and December 2018, 1,812 (25.3%) suffered stroke caused by AF. Frequency of patients with recommended anticoagulation increased within the observation period from 66.7 to 95.8% (per year; adjusted odds ratio [OR], 1.309; confidence interval [CI], 1.153-1.486). Independently from this time trend, DOAC approval (adjusted OR, 4.026; CI 1.962-8.265) and guideline change (adjusted OR, 2.184; CI, 1.006-4.743) were associated with an increasing frequency of recommendation for anticoagulation. The rate of patients already receiving recommended anticoagulation for secondary prevention at discharge increased from 42.1 to 62.5%. Introduction of DOACs was not associated with this trend, and guideline change was even associated with decreasing frequency of anticoagulated patients at hospital discharge (adjusted OR, 0.641; CI, 0.414-0.991). Fear of early intracerebral bleeding was the most common reason for withholding anticoagulation (37%) at hospital dis-Christian Gronemann and Stephan Hause contributed equally to this article.

Deceptive Adherence to Anticoagulation in Secondary Stroke Prevention

“…In majority of the patients, AF had been diagnosed before stroke, but less than half of these patients were on anticoagulants. The underuse of OACs in patients with AF prior to stroke has also been shown by other studies [ 4 , 6 – 8 , 14 , 20 ].…”

“…The patients who did not start or were not prescribed OAC after stroke occurrence (n = 151) were significantly older (82:5 ± 9:1 years; p < 0:001) and had more severe stroke (median NIHSS [IQR] at discharge 12 [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]; p < 0:001), 82% died within 1 year following the index stroke. The characteristics of patients who were not prescribed OAC and those who did not purchase the prescription were not significantly different.…”

“…While there have been numerous studies reporting realworld data on OAC use and therapy adherence in AF patients, much less is known about OAC treatment following an ischemic stroke [6][7][8][9][10][11][12][13][14]. These studies on OAC in stroke patients have reported somewhat different results depending on the aim of the study, methods used, and type of patient cohort and/or time of evaluation after stroke.…”

Association between 24-hour blood pressure parameters and 90-day functional outcome in acute ischemic stroke patients with early anticoagulation

“…BP index plays a more important role in patients treated with special strategy in acute stage of stroke, and specific high BP thresholds are given for thrombolysis and thrombectomy patients. [10,11] Compared with antiplatelet therapy, anticoagulation, intravenous thrombolysis, arterial thrombectomy or bridging strategies are classified as specialized or individual therapy. Nowadays, the most proportion of studies have focused on the association between BP/BPV and prognosis in patients receiving intravenous thrombolysis [12,13] and arterial thrombolysis.…”