Association of Preceding Antithrombotic Treatment With Acute Ischemic Stroke Severity and In-Hospital Outcomes Among Patients With Atrial Fibrillation.

Xian, Ying

O'Brien, Emily C

Liang, Li

Xu, Haolin

Schwamm, Lee H

Fonarow, Gregg C

Bhatt, Deepak L

Smith, Eric E

Olson, DaiWai M

Maisch, Lesley

Hannah, Deidre

Lindholm, Brianna

Lytle, Barbara L

Pencina, Michael J

Hernandez, Adrian F

Peterson, Eric D

2020-11-09T19:26:33Z

2020-11-09T19:26:33Z

2017-03

2020-11-09T19:26:31Z

Importance:Antithrombotic therapies are known to prevent stroke for patients with atrial fibrillation (AF) but are often underused in community practice. Objectives:To examine the prevalence of patients with acute ischemic stroke with known history of AF who were not receiving guideline-recommended antithrombotic treatment before stroke and to determine the association of preceding antithrombotic therapy with stroke severity and in-hospital outcomes. Design, Setting, and Participants:Retrospective observational study of 94 474 patients with acute ischemic stroke and known history of AF admitted from October 2012 through March 2015 to 1622 hospitals participating in the Get With the Guidelines-Stroke program. Exposures:Antithrombotic therapy before stroke. Main Outcomes and Measures:Stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS; range of 0-42, with a higher score indicating greater stroke severity and a score ≥16 indicating moderate or severe stroke), and in-hospital mortality. Results:Of 94 474 patients (mean [SD] age, 79.9 [11.0] years; 57.0% women), 7176 (7.6%) were receiving therapeutic warfarin (international normalized ratio [INR] ≥2) and 8290 (8.8%) were receiving non-vitamin K antagonist oral anticoagulants (NOACs) preceding the stroke. A total of 79 008 patients (83.6%) were not receiving therapeutic anticoagulation; 12 751 (13.5%) had subtherapeutic warfarin anticoagulation (INR <2) at the time of stroke, 37 674 (39.9%) were receiving antiplatelet therapy only, and 28 583 (30.3%) were not receiving any antithrombotic treatment. Among 91 155 high-risk patients (prestroke CHA2DS2-VASc score ≥2), 76 071 (83.5%) were not receiving therapeutic warfarin or NOACs before stroke. The unadjusted rates of moderate or severe stroke were lower among patients receiving therapeutic warfarin (15.8% [95% CI, 14.8%-16.7%]) and NOACs (17.5% [95% CI, 16.6%-18.4%]) than among those receiving no antithrombotic therapy (27.1% [95% CI, 26.6%-27.7%]), antiplatelet therapy only (24.8% [95% CI, 24.3%-25.3%]), or subtherapeutic warfarin (25.8% [95% CI, 25.0%-26.6%]); unadjusted rates of in-hospital mortality also were lower for those receiving therapeutic warfarin (6.4% [95% CI, 5.8%-7.0%]) and NOACs (6.3% [95% CI, 5.7%-6.8%]) compared with those receiving no antithrombotic therapy (9.3% [95% CI, 8.9%-9.6%]), antiplatelet therapy only (8.1% [95% CI, 7.8%-8.3%]), or subtherapeutic warfarin (8.8% [95% CI, 8.3%-9.3%]). After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeutic warfarin, NOACs, or antiplatelet therapy was associated with lower odds of moderate or severe stroke (adjusted odds ratio [95% CI], 0.56 [0.51-0.60], 0.65 [0.61-0.71], and 0.88 [0.84-0.92], respectively) and in-hospital mortality (adjusted odds ratio [95% CI], 0.75 [0.67-0.85], 0.79 [0.72-0.88], and 0.83 [0.78-0.88], respectively). Conclusions and Relevance:Among patients with atrial fibrillation who had experienced an acute ischemic stroke, inadequate therapeutic anticoagulation preceding the stroke was prevalent. Therapeutic anticoagulation was associated with lower odds of moderate or severe stroke and lower odds of in-hospital mortality.

2610336

0098-7484

1538-3598

https://hdl.handle.net/10161/21687

eng

American Medical Association (AMA)

JAMA

10.1001/jama.2017.1371

Humans

Atrial Fibrillation

Acute Disease

Warfarin

Fibrinolytic Agents

Anticoagulants

Platelet Aggregation Inhibitors

International Normalized Ratio

Administration, Oral

Severity of Illness Index

Prevalence

Hospital Mortality

Odds Ratio

Retrospective Studies

Aged

Aged, 80 and over

Female

Male

Stroke

Association of Preceding Antithrombotic Treatment With Acute Ischemic Stroke Severity and In-Hospital Outcomes Among Patients With Atrial Fibrillation.

Journal article

Xian, Ying|0000-0002-1237-1162

O'Brien, Emily C|0000-0002-8257-7561

Xu, Haolin|0000-0003-1069-9567

Pencina, Michael J|0000-0001-5798-8855|0000-0002-1968-2641

Hernandez, Adrian F|0000-0003-3387-9616

Peterson, Eric D|0000-0002-5415-4721

1057

1067

10

School of Medicine

Duke Clinical Research Institute

Population Health Sciences

Neurology

Duke

Institutes and Centers

Basic Science Departments

Clinical Science Departments

Neurology, Neurocritical Care

Medicine, Clinical Pharmacology

Medicine

Biostatistics & Bioinformatics

Medicine, Cardiology

Faculty

Staff

Published

317