Stroke Prevention in Atrial Fibrillation

Chiang, Chern‐En; Chao, Tze‐Fan; Choi, Eue‐Keun; Lim, Toon Wei; Krittayaphong, Rungroj; Li, Mingfang; Chen, Minglong; Guo, Yutao; Okumura, Ken; Lip, Gregory Y.H.

doi:10.1016/j.jacasi.2022.06.004

Cited by 10 publications

(12 citation statements)

References 151 publications

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“…High bleeding risks should not be a reason to withhold anticoagulants. 10 This study had several limitations. The topography of brain infarcts and the mechanisms of strokes could not be specified because we were unable to review electrocardiography and neuroimaging findings.…”

Section: Discussionmentioning

confidence: 93%

“…Current guidelines have suggested that anticoagulants, including vitamin-K antagonists and direct-acting oral anticoagulants (DOACs), effectively reduced the risks of IS and systemic embolization in patients with AF. 4,9,10 However, the prescription rates of anticoagulants in previous studies of patients with NAF were relatively low. 5,6,8 The benefits of anticoagulant treatment in NAF and the long-term prognosis need further investigation.…”

Section: Introductionmentioning

confidence: 99%

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Outcomes in patients with ischemic stroke and newly diagnosed atrial fibrillation after stroke

Chang,

Hsu,

Huang

et al. 2023

Preprint

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BACKGROUNDThe clinical characteristics and long-term outcomes of patients with ischemic stroke (IS) and newly diagnosed atrial fibrillation after stroke (NAF) have not been clearly established. Previous studies evaluating patients with NAF were limited by the low prescription rates of anticoagulants and short follow-up periods.METHODSConsecutive patients hospitalized for IS between 2014 and 2017 were identified from a National Health Insurance Research Database. The included patients were categorized into three groups: (1) known diagnosis of AF (KAF) before the index stroke, (2) NAF, and (3) without AF (non-AF). Univariable and multivariable Cox regression analyses were performed to estimate the hazard ratio (HR) for independent variables and recurrent IS, hemorrhagic stroke, or death.RESULTSWe identified 158,909 patients with IS of whom 16,699 (10.5%) had KAF and 7,826 (4.9%) had NAF. The patients with NAF were younger, more often male, and had lower CHA2DS2-VASc scores (3.8 ± 1.9 versus 4.9 ± 1.8,p< 0.001) than the patients with KAF. Anticoagulant treatment significantly reduced the risks of all outcomes. Compared with NAF, KAF was associated with lower risks of recurrent IS [hazard ratio (HR): 0.91, 95% confidence interval (CI): 0.86–0.97,p< 0.01] and hemorrhagic stroke (HR: 0.88, 95% CI: 0.79–0.99,p< 0.01) and a higher risk of all-cause mortality (HR: 1.11, 95% CI: 1.07–1.16,p< 0.001). The risks of all three outcomes were significantly higher for both NAF and KAF than for non-AF.CONCLUSIONSThe risks of recurrent IS and hemorrhagic stroke were higher and of all-cause mortality was lower for patients with NAF than with KAF. Anticoagulant therapy significantly reduced the risks of recurrent IS, hemorrhagic stroke, and all-cause mortality.

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Section: Discussionmentioning

confidence: 93%

Section: Introductionmentioning

confidence: 99%

Outcomes in patients with ischemic stroke and newly diagnosed atrial fibrillation after stroke

Chang,

Hsu,

Huang

et al. 2023

Preprint

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“…The calculation of bleeding risk scores is crucial for physicians to identify and mitigate existing risk factors, which helps reduce the incidence of bleeding complications, rather than avoiding anticoagulant therapy altogether. The JACC: Asia Statement recommends reassessing stroke and bleeding risk scores at every follow-up appointment, or at a minimum, annually ( 4 ).…”

Section: Introductionmentioning

confidence: 99%

Survey of Using Oral Anticoagulants in Patient with Non-valvular Atrial Fibrillation

Dung,

Hien,

Hoa

et al. 2024

Med Arch

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Background: In Vietnam, there has been no survey conducted on the prescribing and monitoring practices of oral anticoagulants to ensure that patients with atrial fibrillation receive appropriate. Objective: Therefore, we conducted this research to clarify the aforementioned issue in our hospital. Methods: We carried out a cross-sectional study by reviewing outpatient electronic medical records at the University Medical Center in Ho Chi Minh City. Our study included 1087 patients aged 18 years or older diagnosed with non-valvular atrial fibrillation (NVAF), who visited the Cardiology clinic between January 1st, 2021, and June 30th, 2021. Results: Among the 1087 patients with non-valvular atrial fibrillation (NVAF), 1036 were eligible for anticoagulant therapy. However, only 847 (81.8%) received prescriptions for either Vitamin K antagonists (VKAs) (n=129, 15.2%) or Non-Vitamin K antagonist oral anticoagulants (NOACs) (n=718, 84.8%). NOAC prescriptions were more commonly found in patients aged 75 or older (adjusted odds ratio [OR]=2), those with health insurance coverage (adjusted OR=2.9), and in individuals with a history of hypertension (adjusted OR=2). On the contrary, patients with a farming occupation were less likely to be prescribed NOACs (adjusted OR=0.4). About 75% of patients adhered to the guidelines recommending close monitoring during anticoagulant treatment. Notably, inappropriate prescriptions were identified in 27.7% of cases, especially among those with no recorded body weight (which is necessary for precise dosing based on creatinine clearance), those without health insurance, those with undocumented CHA2DS2-VASc scores, or those who were concurrently using antiplatelet agents. Conclusion: A discrepancy persists between clinical guidelines and the actual practice in diagnosing and managing patients with non-valvular atrial fibrillation (NVAF). It is crucial to prioritize the regular reevaluation of thromboembolic risk scores at follow-up appointments, ensure strict adherence to clinical monitoring standards, and align anticoagulant medication prescriptions with established guidelines.

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“…24 Our study is in support of contemporary guideline recommendations that the default should be to offer stroke prevention with OAC (with NOACs being the preferred option) unless the patient is low risk. 1,25 Given the dynamic nature of bleeding risk, efforts to mitigate modifiable bleeding risk factors and schedule regular review and follow up should 14 be undertaken. 23 This was shown prospectively in the bleeding analysis from the mAFA-II trial, where the intervention clusters had less major bleeding and an increase in OAC use at one year, compared to usual care.…”

mentioning

confidence: 99%

“…24 Our study is in support of contemporary guideline recommendations that the default should be to offer stroke prevention with OAC (with NOACs being the preferred option) unless the patient is low risk. 1,25 Given the dynamic nature of bleeding risk, efforts to mitigate modifiable bleeding risk factors and schedule regular review and follow up should . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.…”

mentioning

confidence: 99%

Temporal trends of stroke severity and the association between antithrombotic drug regimen changes and clinical outcomes after stroke in atrial fibrillation

Liao,

Chan,

Kuo

et al. 2023

Preprint

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BackgroundStroke prevention is central to the management of patients with atrial fibrillation (AF) but the impact of NOACs on stroke severity from a nationwide perspective, and the impact of changes in antithrombotic regimen following an ischaemic stroke on subsequent clinical events is unceratin. The aims of the present study were as follows: (i) to describe the temporal trends in OAC use between 2012-2018, and the relationship to stroke severity at presentation; (ii) to describe antithrombotic therapy prescribing patterns following an ischaemic stroke, and the impact of post-stroke thromboprophylaxis on outcomes; and (iii) to assess the impact of changing OAC strategy in AF patients on a NOAC presenting with an ischaemic stroke.MethodsFrom 2007 to 2018, a total of 63,365 patients were identified from the “National Health Insurance Research Database (NHIRD)” in Taiwan. The stroke prevention strategy before and after ischemic stroke and its association to stroke severity was analysed. Subsequent clinical events after ischaemic stroke included recurrent ischaemic stroke, intracranial haemorrhage (ICH), major bleeding, all-cause mortality and composite outcomes.ResultsThe temporal trend disclosed that the overall OAC prescription rate was rising, with warfarin used declining and NOACs use increasing, which was associated with a gradual decline of moderate-severe and severe strokes. The post-stroke antithrombotic strategy was variable. Compared to NOACs post-stroke, there was a significant increase in ischaemic stroke and mortality in non-anticoagulated (adjusted hazard ratios [aHRs] 1.804 and 3.441, respectively) and antiplatelet users (aHRs 1.785 and 1.483, respectively). Warfarin use post-stroke was associated with a significantly incresaed risk of major bleeding compared to NOACs (aHR 2.839). Non-anticoagulated and antiplatelet users were associated with higher risks of both composite outcomes compared to NOAC. Among 769 patients who received NOACs before stroke and continued NOAC post-stroke, there was a higher risk of ischaemic stroke and composite outcomes with no difference in major bleeding, mortality or ICH if patients were changed to a different NOAC post-stroke.ConclusionsIn this nationwide cohort study, increasing use of NOACs was associated with a decline of moderate-severe and severe strokes. Compared to NOACs, non-anticoagulation and antiplatelet use were associated with a significant increase in ischaemic stroke, mortality, and the composite outcome with no significant differences in bleeding events. There was no significant difference of ischemic stroke, mortaltiy, and ICH between post-stroke warfarin and NOAC use but warfarin was associated with a significantly increased risk of major bleeding. A change of NOAC types after ischemic stroke was associated with a two-fold higher risk of ischaemic stroke and the composite outcomes.

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Stroke Prevention in Atrial Fibrillation

Cited by 10 publications

References 151 publications

Outcomes in patients with ischemic stroke and newly diagnosed atrial fibrillation after stroke

Outcomes in patients with ischemic stroke and newly diagnosed atrial fibrillation after stroke

Survey of Using Oral Anticoagulants in Patient with Non-valvular Atrial Fibrillation

Temporal trends of stroke severity and the association between antithrombotic drug regimen changes and clinical outcomes after stroke in atrial fibrillation

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