Changes in anticoagulation practice in subjects admitted with stroke associated with atrial fibrillation, following introduction of direct oral anticoagulants over 2013–2021

Abstract

Background. The adoption of Direct Oral Anticoagulants (DOACs) have changed practice in prevention of stroke in Atrial Fibrillation (AF). We used Irish data national data on stroke and anticoagulation therapy over 9 years to investigate changes in anticoagulation practice and potential consequences on stroke prevalence and thrombolysis., Methods. AF, anticoagulation, thrombolysis and stroke data from the Irish National Audit of Stroke (INAS) 2013-2021 were reviewed. The proportion of patients with ischaemic stroke (IS) and intracerebral haemorrhage (IH) with known AF admitted on anticoagulation were determined. Effects on age distribution in the population and thrombolysis practice were assessed. Results. AF data was available on 34630 of 35241 individuals (98.3%) included in INAS; median age was 74 and 56% were male. AF was found in 10016 (28.9%, 9059 IS, 957 IH). 6313 had known AF prior to stroke (63.1%). The proportion all total ischaemic stroke due to AF decreased by 15.3% (31.3% -26.5%, Chi Square 24.6 p<0.0001). The proportion of IH did not change significantly (21.6%-20.2% Chi Square 1.8, p=0.18). Over the 9 years, 3875 (38.6%) of the subjects with AF were recorded as receiving anticoagulants at admission. In 2013, 4.4% of AF associated strokes were admitted on a DOAC and 21.4% on Warfarin; by 2021 44.1% were receiving a DOAC and 6.2% Warfarin. There was a strong inverse correlation between the proportion of anticoagulated stroke patients and the total proportion of AF associated strokes over time (r=-0.82, p=0.006). In contrast no correlation was found between increasing DOAC usage and IH (r=0.14, p=0.71). Increased anticoagulation usage correlated with a reduction in patients ≥80 years (r=-0.83, p=0.006), and also correlated with a relative reduction of 30.1% in subjects thrombolysed <4 hours from onset (r=-0.89 p=0.001) Conclusion. DOACs have led to increased use of anticoagulation but Warfarin use fell by two thirds. There has been a reduction in the proportion of AF associated IS without a noticeable increase in intracerebral haemorrhage. Increased anticoagulation correlated with reduced numbers of strokes in those >80 years, and in the proportion of patients thrombolysed.

The Desirable Effects of Edoxaban on Thrombi in the Left Atrium Are Seemingly Connected to Pulmonary Vein Thrombi

“…Direct oral anticoagulants (DOACs) are useful for preventing the occurrence and recurrence of IS [10,[17][18][19]; however, the mechanisms underlying the effectiveness of DOACs are poorly understood. Using 80-MDCT and TEE, we reported that rivaroxaban partially dissolved LA thrombi and PVTs [6]; however, the effects of edoxaban on LA thrombi and PVTs are unclear.…”

Anticoagulation Usage and Thrombolytic Therapy in Subjects with Atrial Fibrillation Associated Ischaemic Stroke

“…In light of this, INAS undertook a further review of the data and requested centres to collect an additional data on AF and anticoagulation for the calendar year 2022 to examine more closely prescribing practices adherence with therapy and to determine if they were less optimal that in other populations (4). In addition, INAS had noted a small reduction in the proportion of patients receiving thrombolysis in the preceding few years and it was hypothesised that an increase in the use of DOAC therapy, an absolute contraindication to thrombolysis, may have had an influence on proportion of people thrombolysed (5).…”