Anticoagulation Therapy for Stroke Prevention in Atrial Fibrillation

Go, Alan S.; Hylek, Elaine M.; Chang, Yuchiao; Phillips, Kathleen A.; Henault, Lori; Capra, Angela M.; Jensvold, Nancy G.; Selby, Joe V.; Singer, Daniel E.

doi:10.1001/jama.290.20.2685

Cited by 621 publications

(159 citation statements)

References 43 publications

(31 reference statements)

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“…Although this rate is within the range reported in previous hospital-based studies [7, 20, 21], it still raises concern about the effectiveness of OAC in daily routine. Nevertheless, the rate of recurrent stroke was about 2% and comparable to a nonrandomized as well as large randomized studies in patients with AF [22, 23], while the rate of intracranial hemorrhage is of limited value due to only 2 observations (1 subdural and 1 intracranial) leading to wide confidence intervals. No follow-up data after 1–2 years were available from AF patients without OAC, but these patients were significantly different from AF patients discharged on OAC and had a significantly worse prognosis in other large observational studies [6, 14].…”

Section: Discussionsupporting

confidence: 61%

Adherence and Quality of Oral Anticoagulation in Cerebrovascular Disease Patients with Atrial Fibrillation

et al. 2008

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Background/Aims: Low rates and poor quality of oral anticoagulation (OAC) have been reported in patients with atrial fibrillation (AF). We therefore sought to investigate the prescription patterns at discharge, adherence and quality of OAC in cerebrovascular disease patients with AF. Methods: Consecutive ischemic stroke (IS) and transient ischemic attack (TIA) patients were prospectively documented in 11 German stroke centers. A central telephone follow-up after 1–2 years assessed the current antithrombotic medication and results of coagulation checks. Results: Of 1,463 surviving patients with AF, 30.5% were discharged on OAC and 13.9% on high-dose heparin. Of 329 AF patients discharged on OAC and with consent for follow-up, 88.7% of surviving patients were still on OAC at the follow-up. Of these, 52.7% reported coagulation values out of the therapeutic range during the preceding 3 months. A recurrent IS was seen in 9 patients (2.1%/year) and an intracranial hemorrhage in 2. Conclusion: We found an important underuse of OAC following TIA or IS mainly in older patients and with greater stroke-related disability. Although the reported coagulation checks showed an only moderate rate within therapeutic ranges, safety and efficacy of OAC in this cohort seem comparable to previous randomized and observational trials in AF patients.

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Section: Discussionsupporting

confidence: 61%

Adherence and Quality of Oral Anticoagulation in Cerebrovascular Disease Patients with Atrial Fibrillation

et al. 2008

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“…The index date of warfarin therapy was defined as new warfarin dispensing without prior evidence of receiving warfarin within 3 years before the index dispensing date. Time on warfarin was based on the number of days supplied per prescription and intervening international normalized ratio (INR) tests using a previously validated algorithm 12. We included adults who were ≥21 years at their index warfarin prescription date, had at least 1 outpatient INR measurement after the index date, and had ≥12 months of continuous health plan membership and pharmacy drug benefit before study entry to ensure minimum necessary information on patient characteristics.…”

Section: Methodsmentioning

confidence: 99%

Anxiety, Depression, and Adverse Clinical Outcomes in Patients With Atrial Fibrillation Starting Warfarin: Cardiovascular Research Network WAVE Study

Baumgartner

Fan

Fang

et al. 2018

JAHA

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BackgroundAnxiety and depression are associated with worse outcomes in several cardiovascular conditions, but it is unclear whether they affect outcomes in atrial fibrillation (AF). In a large diverse population of adults with AF, we evaluated the association of diagnosed anxiety and/or depression with stroke and bleeding outcomes.Methods and ResultsThe Cardiovascular Research Network WAVE (Community‐Based Control and Persistence of Warfarin Therapy and Associated Rates and Predictors of Adverse Clinical Events in Atrial Fibrillation and Venous Thromboembolism) Study included adults with AF newly starting warfarin between 2004 and 2007 within 5 health delivery systems in the United States. Diagnosed anxiety and depression and other patient characteristics were identified from electronic health records. We identified stroke and bleeding outcomes from hospitalization databases using validated International Classification of Diseases, Ninth Revision (ICD‐9), codes. We used multivariable Cox regression to assess the relation between anxiety and/or depression with outcomes after adjustment for stroke and bleeding risk factors. In 25 570 adults with AF initiating warfarin, 490 had an ischemic stroke or intracranial hemorrhage (1.52 events per 100 person‐years). In multivariable analyses, diagnosed anxiety was associated with a higher adjusted rate of combined ischemic stroke and intracranial hemorrhage (hazard ratio, 1.52; 95% confidence interval, 1.01–2.28). Results were not materially changed after additional adjustment for patient‐level percentage of time in therapeutic anticoagulation range on warfarin (hazard ratio, 1.56; 95% confidence interval, 1.03–2.36). In contrast, neither isolated depression nor combined depression and anxiety were significantly associated with outcomes.ConclusionsDiagnosed anxiety was independently associated with increased risk of combined ischemic stroke and intracranial hemorrhage in adults with AF initiating warfarin that was not explained by differences in risk factors or achieved anticoagulation quality.

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“…Oral anticoagulants are highly effective for stroke prevention in patients with atrial fibrillation,1, 2 but strict adherence to medication is crucial for maximizing treatment benefits. There is hope that non–vitamin K antagonist oral anticoagulants (NOACs) may improve adherence, because of less burden of treatment compared with warfarin 3, 4, 5.…”

Section: Introductionmentioning

confidence: 99%

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

Yao

Abraham

Alexander

et al. 2016

JAHA

390

329

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BackgroundIn comparison to warfarin, non–vitamin K antagonist oral anticoagulants (NOACs) have the advantages of ease of dosing, fewer drug interactions, and lack of need for ongoing monitoring. We sought to evaluate whether these advantages translate to improved adherence and whether adherence is associated with improved outcomes in patients with atrial fibrillation.Methods and ResultsWe performed a retrospective cohort analysis by using a large US commercial insurance database to identify 64 661 patients with atrial fibrillation who initiated warfarin, dabigatran, rivaroxaban, or apixaban treatment between November 1, 2010, and December 31, 2014. During a median of 1.1 y of follow‐up, 47.5% of NOAC patients had a proportion of days covered of ≥80%, compared with 40.2% in warfarin patients (P<0.001). Patients with CHA 2 DS 2‐VASc (risk based on the presence of congestive heart failure, hypertension age 65–74 y, age ≥75 y, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, sex category) score ≥4 were at increased risk of stroke when they were not taking anticoagulation ≥1 month versus <1 week (1–3 months: hazard ratio [HR] 1.96, 3–6 months: HR 2.64, ≥6 months: HR 3.66; all P<0.001). Patients with CHA 2 DS 2‐VASc score 2 or 3 were at increased risk of stroke when they were not taking anticoagulation ≥6 months (HR 2.73, P<0.001). In these patients with CHA 2 DS 2‐VASc score ≥2, nonadherence was not associated with intracranial hemorrhage. Among patients with CHA 2 DS 2‐VASc score 0 or 1, time not taking anticoagulation was not associated with stroke, but not taking anticoagulation ≥3 months was associated with a significant reduction of bleeding.ConclusionsAdherence to anticoagulation is poor in practice and may be modestly improved with NOACs. Adherence to therapy appears to be most important in patients with CHA 2 DS 2‐VASc score ≥2, whereas the benefits of anticoagulation may not outweigh the harms in patients with CHA 2 DS 2‐VASc score 0 or 1.

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Anticoagulation Therapy for Stroke Prevention in Atrial Fibrillation

Cited by 621 publications

References 43 publications

Adherence and Quality of Oral Anticoagulation in Cerebrovascular Disease Patients with Atrial Fibrillation

Adherence and Quality of Oral Anticoagulation in Cerebrovascular Disease Patients with Atrial Fibrillation

Anxiety, Depression, and Adverse Clinical Outcomes in Patients With Atrial Fibrillation Starting Warfarin: Cardiovascular Research Network WAVE Study

Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With Atrial Fibrillation

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