Trends in utilization of antithrombotic therapy in patients with atrial fibrillation before stroke onset in a community-based study, from 1985 through 1997

Osseby, Guy‐Victor; Bénatru, Isabelle; Sochůrková, Daniela; Urbinelli, Renaud; Megherbi, Salah-Eddine; Couvreur, G.; Moreau, Thibault; Wolf, Jean-Éric; Giroud, Maurice

doi:10.1016/j.ypmed.2003.09.002

Cited by 21 publications

(11 citation statements)

References 28 publications

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“…Although studies have demonstrated the underutilization of warfarin, especially in women, for stroke prevention in AF, [17][18][19][20][21][22][23][24][25] female sex was not independently related to warfarin or aspirin use in our study. Some studies have shown that the efficacy of warfarin is lower in women, 26 but this could not be analyzed in our study.…”

Section: Stroke Risk After First Af and Time Trendscontrasting

confidence: 87%

Time Trends of Ischemic Stroke Incidence and Mortality in Patients Diagnosed With First Atrial Fibrillation in 1980 to 2000

Miyasaka

Barnes

Gersh

et al. 2005

Stroke

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Background and Purpose-With the changes in management of atrial fibrillation (AF) over time, it is possible that the time trends of post-AF stroke incidence and mortality have changed. We sought to determine whether the incidence and survival of ischemic stroke after AF diagnosis have improved. Methods-We identified the Olmsted County, Minn, residents who developed first AF from 1980 to 2000 and followed them in medical records to 2004. The outcomes were first ischemic stroke and death. Results-Of the 4117 subjects diagnosed with first AF and without previous stroke, 446 (11%) sustained a first ischemic stroke during a mean follow-up time of 5.5Ϯ5.0 years. The age-and sex-adjusted incidence of stroke decreased, on average, by 3.4% per year (Pϭ0.0001), concurrent with an increase in warfarin and aspirin use (both PϽ0.0001) and reduction of systolic blood pressure (PϽ0.001). The age-adjusted ischemic stroke incidence was higher in women (Pϭ0.039), but not after adjusting for systolic blood pressure (Pϭ0.41). Compared with the general Minnesota white population, the relative mortality hazard ratio was 1.88 for men and 1.84 for women without stroke and 3.03 for men and 3.80 for women (PϽ0.05) with stroke. The relative mortality hazard did not vary by age or calendar year of AF diagnosis. Conclusions-Post-AF ischemic stroke incidence decreased significantly from 1980 to 2000, during which time a substantial increase in the use of antithrombotic therapy and reduction of systolic blood pressure was evident. The relative mortality risk of stroke, however, had not improved over time.

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Section: Stroke Risk After First Af and Time Trendscontrasting

confidence: 87%

Time Trends of Ischemic Stroke Incidence and Mortality in Patients Diagnosed With First Atrial Fibrillation in 1980 to 2000

Miyasaka

Barnes

Gersh

et al. 2005

Stroke

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“…Another Italian study not only found that risk stratification only partially influences antithrombotic management but also that underuse and discontinuation of anticoagulant treatment is common in incident AF patients (32). The results of our sensitivity analyses did not echo those of a French study (33) that identified 1992-1994 as the period of most significant increase in the use of anticoagulants (14.6% in 1985-1987 compared (11)], and previous research suggests that best practice has frequently not been applied even when relatively widely known.…”

Section: Comparison With Existing Literaturecontrasting

confidence: 92%

Treatment pathways for patients with atrial fibrillation

Hodgkinson

Taylor

Hobbs

2011

International Journal of Clinical Practice

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BackgroundAtrial fibrillation (AF) is a common rhythm disorder and the most common chronic arrhythmia. AF is associated with increased morbidity and mortality (1), and, in particular, is a major independent risk factor for stroke (2), particularly in older patients. The prevalence of AF in the UK is more than 12⁄ 1000, but this increases to at least 10% in people aged 85 years and over (3) or to 16% according to recent data (4).Atrial fibrillation represents a challenging arrhythmia. A rational approach to management of the individual case depends on careful assessment of the temporal pattern of the arrhythmia, any associated cardiovascular disease and any particular features suggesting the advisability or risks of specific treatment regimens. The nature of an arrhythmia and of individual patient factors changes over time, requiring a flexible approach to long-term treatment that may be defined only after months or years (5). In particular, key considerations are the use of anticoagulants and ⁄ or antiplatelets as antithrombotic therapy, and the pursuance of a rate-or rhythm-control approach. SUMMARYBackground: Although there has been growing concordance over what constitutes best practice in recent guidelines for treatment of atrial fibrillation (AF), notably regarding anticoagulant use, it remains unclear whether patients are being treated accordingly. Aims: The aims of this study were to explore the pattern of treatment pathways -i.e. how patients are treated over time -for patients with AF, and to test the hypothesis that comparative to patients in lower stroke-risk categories (as measured by CHADS 2 score), patients with higher CHADS 2 scores are less likely to discontinue anticoagulant therapy or, if not started on anticoagulant treatment, more likely to be transferred to anticoagulant therapy, in keeping with guideline recommendations. Setting: A total of 67,857 patients with a diagnosis of AF in practices registered with the General Practice Research Database. Methods: A series of possible treatment pathways were identified, and for each initial treatment, we estimated the probability of treatment change and the average time that a patient newly diagnosed with AF spent on a particular treatment, projected across 5 years and stratified by CHADS 2 score. Results: There was no relationship between CHADS 2 score and maintenance or discontinuation of particular approaches to antithrombotic treatment. While those beginning on antiplatelet therapy were more likely to change treatment than those on anticoagulants (approximately 60% vs. 50% within the first year), as much as one-third of treatment time of all those starting on a therapeutic approach involving anticoagulants featured no use of anticoagulants (either as monotherapy or in combination) over the 5-year period, and whether treatment was discontinued or maintained did not vary by CHADS 2 score. No difference was found in treatment pathways controlling for post-2002 diagnoses as against the whole sample. Conclusions: Although there is more evidence of tr...

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“…This increase occurred after the publication of trials demonstrating the efficacy of warfarin for the primary and secondary prevention of ischemic stroke among patients with atrial fibrillation, and it coincides with data showing increased warfarin use in these populations. [11][12][13][14] Patients with anticoagulant-associated ICH had poorer outcomes in our Cox regression model, consistent with previous reports demonstrating greater risk of hematoma expansion and worse survival among anticoagulated ICH patients than those without coagulopathy. 15,16 Increasing age and diabetes have likewise been associated with worse outcomes.…”

supporting

confidence: 87%

Asymptomatic sinovenous thrombosis in a healthy neonate

Golomb

Edwards-Brown²,

Garg³

2006

Neurology

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Abstract-Objective:To characterize long-term mortality following intracerebral hemorrhage (ICH) in two large population-based cohorts assembled more than a decade apart. Methods: All patients age Ն18 hospitalized with nontraumatic ICH in the Greater Cincinnati/Northern Kentucky area were identified during 1988 (Cohort 1) and from May 1998 to July 2001 and August 2002 to April 2003. Mortality was tabulated using actuarial methods and compared with a log-rank test. Results: There were 183 patients with ICH in Cohort 1 and 1,041 patients in Cohort 2. Patients in Cohort 1 were more likely to be white (p ϭ 0.024) and undergo operation for their ICH (p ϭ 0.002), whereas patients in Cohort 2 were more commonly on anticoagulants (p Ͻ 0.001). Among patients in Cohort 1, mortality at 7 days, 1 year, and 10 years was 31, 59, and 82%. Among patients in Cohort 2, mortality at 7 days and 1 year was 34 and 53%. Mortality rates did not differ between cohorts by log-rank test (p ϭ 0.259). Conclusions: Intracerebral hemorrhage (ICH) mortality did not improve significantly between study periods. Operation for ICH became less frequent, whereas anticoagulant-associated ICH became more common. NEUROLOGY 2006;66:1182-1186 Recent investigations into the surgical and medical management of intracerebral hemorrhage (ICH) prove that large-scale clinical trials for this condition are feasible and provide hope that new treatments may improve patient outcomes.1,2 Outside of clinical trials, changes in medical practice and the natural history of disease are ideally documented in population-based studies that capture all disease cases within a defined community. To date, most population-based studies of ICH outcome have been small and racially homogeneous.3 Limited sample size has precluded analysis of some predictors of ICH outcome, such as location of hemorrhage and anticoagulant use in most of these studies.3,4 Furthermore, whereas short-term mortality following ICH is known to be high, the pattern of long-term mortality following ICH and recent trends in ICH mortality have not been well documented. 3 We present a population-based study of ICH outcome, including long-term mortality data, stratification by location of hemorrhage, and a comparison of two large ICH cohorts assembled more than a decade apart.Methods. Two ICH cohorts from the five-county Greater Cincinnati/Northern Kentucky area (GCNK) were tracked for this study. Cohort 1 was assembled from January 1988 through December 1988 and has been the subject of previous reports. Factors for Hemorrhagic Stroke (GERFHS) study, an ongoing population-based study of ICH and subarachnoid hemorrhage in the GCNK region. 7 The methodology of the GERFHS study has been previously described. 7,8The current study includes all hospitalized cases of ICH that occurred in persons age Ն18 within the five GCNK metropolitan counties during the prescribed periods. For both cohorts, cases were identified by retrospective review of primary and secondary International Classification of Diseases-9 (ICD-9) codes...

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Trends in utilization of antithrombotic therapy in patients with atrial fibrillation before stroke onset in a community-based study, from 1985 through 1997

Cited by 21 publications

References 28 publications

Time Trends of Ischemic Stroke Incidence and Mortality in Patients Diagnosed With First Atrial Fibrillation in 1980 to 2000

Time Trends of Ischemic Stroke Incidence and Mortality in Patients Diagnosed With First Atrial Fibrillation in 1980 to 2000

Treatment pathways for patients with atrial fibrillation

Asymptomatic sinovenous thrombosis in a healthy neonate

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