Abstract
Objective: Despite the continuous update of clinical guidelines, little is known about the real-world management of patients with atrial fibrillation (AF) who survived a stroke. We aimed to assess patterns of therapeutic management of stroke survivors with AF and clinical outcomes using data from routine practice in a large population-based cohort. Methods: A population-based retrospective cohort study of all patients with AF who survived a stroke, from January 2010 to December 2017 in the Valencia region, Spain (n = 10,986), was carried out. Treatment strategies and mean time to treatment initiation are described. Temporal trends are shown by the management pattern during the study period. Factors associated with each pattern (including no treatment) vs. oral anticoagulant (OAC) treatment were identified using logistic multivariate regression models. Incidence rates of clinical outcomes (mortality, stroke/TIA, GI bleeding, and ACS) were also estimated by the management pattern. Results: Among stroke survivors with AF, 6% were non-treated, 23% were prescribed antiplatelets (APT), 54% were prescribed OAC, and 17% received OAC + APT at discharge. Time to treatment was 8.0 days (CI 7.6–8.4) for APT, 9.86 (CI 9.52–10.19) for OAC, and 16.47 (CI 15.86–17.09) for OAC + APT. Regarding temporal trends, management with OAC increased by 20%, with a decrease of 50% for APT during the study period. No treatment and OAC + APT remained relatively stable. The strongest predictor of no treatment and APT treatment was having the same management strategy pre-stroke. Those treated with APT had the highest rates of GI bleeding and recurrent stroke/TIA, and untreated patients showed the highest rates of mortality. Conclusion: In this large population-based cohort using real-world data, nearly 30% of AF patients who suffered a stroke were untreated or treated with APT, which overall is not recommended. Treatment was started within 2 weeks as recommended, except for OAC + APT, which was started later. The strong association of APT treatment or non-treatment with the same treatment strategy before stroke occurrence suggests a strong therapeutic inertia and opposes recommendations. Patients under these two strategies had the highest rates of adverse outcomes. An inadequate prescription poses a great risk on patients with AF and stroke; thus monitoring their management is necessary and should be setting-specific.
Highlights
Stroke is currently the second leading cause of death and an important contributor to disability-adjusted life years worldwide (Lozano et al, 2012; Murray et al, 2012)
We identified the following variables: age, gender, and country of origin; Clinical factors included the following: baseline diagnosis (AF or flutter), main diagnosis at admission, and several comorbidities including congestive heart failure, hypertension, diabetes mellitus, liver and renal disease, dementia, depression, cancer, coronary heart disease, venous thromboembolism (VTE), intracranial hemorrhage, gastrointestinal bleeding and other bleeding previous to the current admission, and risk scores (CHADS2, CHA2DS2-VASC, and HAS-BLED scores)
The cohort was composed of 10,986 patients with Atrial Fibrillation (AF), discharged alive after an ischemic stroke or transient ischemic attack (TIA), from which 643 (5.9%) did not receive ATT at discharge, 2,530 (23.0%) were prescribed antiplatelets (APT), 5,900 (53.7%) were prescribed OAC, and 1,913 (17.4%) received both (OAC + APT) (Figure 1)
Summary
Stroke is currently the second leading cause of death and an important contributor to disability-adjusted life years worldwide (Lozano et al, 2012; Murray et al, 2012). Atrial Fibrillation (AF), the most common cardiac arrhythmia (Steinberg and Piccini, 2014), increases the risk of stroke and is one of the leading causes of cerebrovascular mortality and morbidity (Jørgensen et al, 1996; Lin et al, 1996). These figures offer a clear picture of the importance of secondary prevention of stroke in patients with AF. Timing of initiation of drug therapy is still an unresolved challenge (Klijn et al, 2019; Seiffge et al, 2019) All these factors make decision making a complex issue for physicians treating these patients. Studies on the real-world management of these patients including the whole picture of all possible treatments (including no treatment) are lacking, and it is unknown if the real world meets guidelines’ recommendations
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
