Trends in Risk of Stroke in Patients with a Hospital Diagnosis of Nonvalvular Atrial Fibrillation: National Cohort Study in Denmark, 1980–2002

Frost, Lars; Andersen, Ljubica Vukelic; Vestergaard, Peter; Husted, Steen; Mortensen, Leif Spange

doi:10.1159/000092795

Cited by 33 publications

(27 citation statements)

References 46 publications

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“…Previously reported incidence rates of stroke are in the same range as in our study but did not include detailed information on VKA use from newly diagnosed patients with AF of the recent years 13 14. For ischaemic stroke, the incidence rate reported by Go et al 15 in patients taking warfarin and for patients not taking warfarin is in agreement with our study.…”

Section: Discussionsupporting

confidence: 91%

Population-based cohort study of warfarin-treated patients with atrial fibrillation: incidence of cardiovascular and bleeding outcomes

et al. 2014

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ObjectivesAtrial fibrillation (AF) is the most common cardiac rhythm disorder with a significant health burden. The aim of this study was to characterise patients with recently diagnosed AF and to estimate the rates of comorbidities and outcome events requiring hospitalisation in routine clinical practice.DesignPharmacoepidemiological cohort study using observational data.Methods/settingThis study included 16 513 patients with a first diagnosis of AF between 1 January 2005 and 28 February 2010 (newly diagnosed patients) using data from the UK Clinical Practice Research Datalink (CPRD) linked to Hospital Episode Statistics (HES) and the Office for National Statistics mortality data. Exposure was stratified by vitamin K antagonist (VKA) exposure (non-use, current, recent and past exposure) based on prescriptions and/or international normalised ratio measurements, and followed for outcome events of interest based on diagnosis codes in the databases, that is, vascular outcomes, bleeding events and others. The main focus of the study was on outcome events requiring hospitalisation using the HES data.ResultsThe incidence of vascular outcome hospitalisations (myocardial infarction (MI), stroke or systemic arterial peripheral embolism) was 3.8 (95% CI 3.5 to 4.0)/100 patient-years. The incidence of stroke was 0.9 (0.8 to 1.1) during current VKA exposure, 2.2 (1.6 to 2.9) for recent, 2.4 (1.9 to 2.9) for past and 3.4 (3.1 to 3.7) during non-use. MI incidence was 0.7 (0.6 to 0.9) for current VKA exposure, 0.7 (0.4 to 1.2) for recent, 1.1 (0.8 to 1.5) for past and 1.9 (1.7 to 2.1) during non-use. The incidence of bleeding event hospitalisations was 3.8 (3.4 to 4.2) for current VKA exposure, 4.5 (3.7 to 5.5) for recent, 2.7 (2.2 to 3.3) for past and 2.9 (2.6 to 3.2) during non-use; 38% of intracranial bleeds and 6% of gastrointestinal bleeds were fatal.ConclusionsThis population-based study from recent years provides a comprehensive characterisation of newly diagnosed patients with AF and incidence estimates of common outcomes with a focus on hospitalised events stratified by VKA exposure. This study will help to place future data on new oral anticoagulants into perspective.

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Section: Discussionsupporting

confidence: 91%

Population-based cohort study of warfarin-treated patients with atrial fibrillation: incidence of cardiovascular and bleeding outcomes

et al. 2014

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“…This decrease in patients >85 years of age, was probably related to competing mortality risks, which showed a sharp increase in incidence rate in both men and women with AF >85 years of age. The rates of ischemic stroke in the present study are comparable to those reported in the Loire Valley Atrial Fibrillation Project 44 in Denmark, 45 in the United States, 46 and in Canada 47 but are somewhat lower than those reported in other studies mostly from Europe. 38,48 Several factors may explain our lower reported rates.…”

Section: Discussionsupporting

confidence: 82%

Prospective National Study of the Prevalence, Incidence, Management and Outcome of a Large Contemporary Cohort of Patients With Incident Non‐Valvular Atrial Fibrillation

Haim

Hoshen

Reges

et al. 2015

JAHA

213

119

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BackgroundThere are few studies of atrial fibrillation (AF) outside of North America or Europe. The aim of the present study was to assess the prevalence, incidence, management and outcomes of patients with new atrial fibrillation, in a large contemporary cohort (2004–2012) of adult patients.Methods and ResultsThe Clalit Health Services (CHS) computerized database of 2 420 000 adults, includes data of community clinic visits, hospital discharge records, medical diagnoses, medications, medical interventions, and laboratory test results. The prevalence of AF on January 1, 2004 was 71 644 (3%). Prevalence and incidence of AF increased with age and was higher in men versus women. During the study period (2004–2012) 98 811 patients developed new non‐valvular AF (mean age −72, 50% women, 46% with cardiovascular disease, 6% with prior stroke). The rate of persistent warfarin use (dispensed for >3 months in a calendar year) was low (25.7%) and it increased with increasing stroke risk score. Individual Time in Therapeutic Range (TTR) among warfarin users was 42%. The incidence rate of ischemic stroke and death increased with age. The rate of stroke increased from 2 per 1000 person years in patients with CHA2DS2_VASC SCORE of 0, to 58 per 1000 person years in those with a score of 9.ConclusionsIn the present study the prevalence and incidence of AF, stroke, and death were comparable to those reported in Europe and North America. The low use of anticoagulation calls for measures to increase adherence to current treatment recommendations in order to improve outcomes.

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“…In a similarly organized cohort study of AF, the hospital diagnosis for AF was well validated; evidence for AF was found in 99%. 29 Another possible limitation is the underreporting of some comorbidities, especially hypertension.…”

Section: Selection Biasmentioning

confidence: 99%

Net Clinical Benefit of Warfarin in Patients With Atrial Fibrillation

2012

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Background— Known risk factors for bleeding during anticoagulant treatment are largely the same as those predicting thromboembolic events in patients with atrial fibrillation (AF). Our objective was to investigate how to maximize the likelihood of avoiding both stroke and bleeding. Methods and Results— All 182 678 subjects with atrial fibrillation in the Swedish Hospital Discharge Register were studied for an average of 1.5 years (260 000 patient-years at risk). Patients were stratified according to risk scores with the use of historic International Classification of Disease diagnostic codes in the register. Information about medication was obtained from the Swedish Drug Registry. Our primary end point was net benefit defined as number of avoided ischemic strokes with anticoagulation minus the number of excess intracranial bleedings with a weight of 1.5 to compensate for the generally more severe outcome with intracranial bleedings. The adjusted net clinical benefit favored anticoagulation for almost all atrial fibrillation patients. The exceptions were patients at very low risk of ischemic stroke with a CHA 2 DS 2 -VASc score of 0 and moderately elevated bleeding risk (−1.7%/y). The results were broadly similar with CHADS 2 , except for patients with very low embolic risk; the CHA 2 DS 2 -VASc was able to identify those patients (n=6205, 3.9% of all patients) who had no net clinical benefit or even some disadvantage from anticoagulant treatment. Conclusions— In almost all patients with atrial fibrillation, the risk of ischemic stroke without anticoagulant treatment is higher than the risk of intracranial bleeding with anticoagulant treatment. Analysis of the net benefit indicates that more patients may benefit from anticoagulant treatment.

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Trends in Risk of Stroke in Patients with a Hospital Diagnosis of Nonvalvular Atrial Fibrillation: National Cohort Study in Denmark, 1980–2002

Cited by 33 publications

References 46 publications

Population-based cohort study of warfarin-treated patients with atrial fibrillation: incidence of cardiovascular and bleeding outcomes

Population-based cohort study of warfarin-treated patients with atrial fibrillation: incidence of cardiovascular and bleeding outcomes

Prospective National Study of the Prevalence, Incidence, Management and Outcome of a Large Contemporary Cohort of Patients With Incident Non‐Valvular Atrial Fibrillation

Net Clinical Benefit of Warfarin in Patients With Atrial Fibrillation

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