Use of Warfarin at Discharge Among Acute Ischemic Stroke Patients With Nonvalvular Atrial Fibrillation in China

Abstract

Background and Purpose— Guidelines recommend oral anticoagulation for ischemic stroke patients with atrial fibrillation, and previous studies have shown the underuse of anticoagulation for these patients in China. We sought to explore the underlying reasons and factors that currently affect the use of warfarin in China. Methods— From June 2012 to January 2013, 19 604 patients with acute ischemic stroke were admitted to 219 urban hospitals voluntarily participating in the China National Stroke Registry II. Multivariable logistic regression models using the generalized estimating equation method were used to identify patient/hospital factors independently associated with warfarin use at discharge. Results— Among the 952 acute ischemic stroke patients with nonvalvular atrial fibrillation, 19.4% were discharged on warfarin. The risk of bleeding (52.8%) and patient refusal (31.9%) were the main reasons for not prescribing anticoagulation. Larger/teaching hospitals were more likely to prescribe warfarin. Older patients, heavy drinkers, patients with higher National Institutes of Health Stroke Scale score on admission were less likely to be given warfarin, whereas patients with history of heart failure and an international normalized ratio between 2.0 and 3.0 during hospitalization were significantly associated with warfarin use at discharge. Conclusions— The rate of warfarin use remains low among patients with ischemic stroke and known nonvalvular atrial fibrillation in China. Hospital size and academic status together with patient age, heart failure, heavy alcohol drinking, international normalized ratio in hospital, and stroke severity on admission were each independently associated with the use of warfarin at discharge. There is much room for improvement for secondary stroke prevention in nonvalvular atrial fibrillation patients in China.

Socioeconomic Status and the Quality of Acute Stroke Care

“…The cutoff point is arbitrary based on our understanding that stroke patients in China have a poorer quality of stroke care in China than those in high-income countries. 5,26 However, if we used the median score of 0.6 or below defined as having a poor quality of care for data analysis, the findings were similar to the current ones (data now shown). Fourth, there might be some stroke patients who did not search for care from hospital or died before hospitalization.…”

“…25 Thus, it would be reasonable for us to use the family income ≤¥1000 per month as SED for analysis. We divided patients into 3 groups according to the tertiles of the composite score of the quality of care and took those who had low 2 tertiles of the score as having the poor quality of stroke care (because China has a generally poorer quality of stroke care than those in high income countries 5,26 ). We examined differences between patients with poor versus good quality of stroke care in continuous variables using t test or Wilcoxon rank-sum test and in categorical variables using Chi-square test.…”

“…29 The quality of stroke care in China is diverse across the country and on the whole poorer than that in western countries, especially for recombinant tissue-type plasminogen activator treatment and warfarin use. 5,26 Knowledge of existing disparities in the quality of stroke care is of importance for improving outcomes of stroke patients. Our study has shown that patients with SED have poorer quality of stroke care.…”

Current Status and Time Trends of Oral Anticoagulation Use Among Chinese Patients With Nonvalvular Atrial Fibrillation

“…In the China National Stroke Registry II conducted from 2012 to 2013, the use of warfarin at discharge among acute ischemic stroke patients with NVAF was only 19.4%. 23 Another registry study conducted between 2009 and 2011 24 reported that the rates of OAC use were 31.7% and 28.3%, respectively, among patients with CHADS 2 scores or CHA 2 DS 2 -VASc scores ≥2. Our data show that further improvements have been achieved in recent years.…”

Substantial Progress Yet Significant Opportunity for Improvement in Stroke Care in China

“…Additionally, physicians are concerned about the safety of using warfarin. 16 New oral anticoagulants are an alternative for warfarin and recommended by guidelines without monitoring INR and increasing the risk of hemorrhage. 17 Increased compliance with acute stroke care and secondary prevention guideline-recommended performance metrics is associated with favorable outcomes.…”