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Published on: February 28, 2012
Antithrombotic therapy after acute ischemic stroke in patients with atrial fibrillation
Emer R McGrath1, Moira K Kapral2, Jiming Fang2
1From the Massachusetts General Hospital, Boston (E.R.M.); National University of Ireland, Galway, Ireland (E.R.M.); University of Toronto, Toronto, Ontario, Canada (M.K.K.); Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada (M.K.K., J.F.); McMaster University, Hamilton, Ontario, Canada (J.W.E.); and National University of Ireland, Galway, Ireland (A.O.C., M.C., M.J.O.). emcgrath2@partners.org.
Insights
Patients with atrial fibrillation and stroke have increased risks when not on oral anticoagulation (OAC) or antiplatelet therapy. Combination therapy may reduce major vascular events, warranting further clinical trials.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Current guidelines recommend oral anticoagulation (OAC) alone for secondary prevention in patients with atrial fibrillation and ischemic stroke (IS).
- A significant proportion of patients do not adhere to these recommendations.
Purpose of the Study:
- To determine the association between discharge antithrombotic regimen and the risk of major vascular events in patients with acute IS and atrial fibrillation.
- To evaluate current treatment practices against established guidelines.
Main Methods:
- A prospective cohort study of 2162 patients with acute IS and atrial fibrillation from the Ontario Stroke Registry.
- Multivariable Cox proportional hazard models were employed to analyze the association between discharge antithrombotic strategies and clinical outcomes.
Main Results:
- At discharge, 8.0% received no antithrombotic therapy, 21.6% received antiplatelet therapy alone, 39.3% received OAC alone, and 31.1% received combination therapy.
- Compared to OAC alone, no antithrombotic therapy (HR 1.51) and antiplatelet therapy alone (HR 1.31) were associated with increased risk of major vascular events.
- Combination OAC and antiplatelet therapy showed a trend toward reduced risk (HR 0.91), particularly in patients with coronary heart disease (HR 0.79).
Conclusions:
- A significant number of patients with atrial fibrillation and recent IS are not prescribed OAC or receive combination therapy, deviating from current guidelines.
- Combination OAC and antiplatelet therapy warrants further investigation in clinical trials, especially with newer OACs, for high-risk cardiovascular patients.
- The findings suggest a need to re-evaluate treatment strategies for secondary prevention in this patient population.
Background And Purpose:
For patients with atrial fibrillation and ischemic stroke (IS), current guidelines recommend oral anticoagulation (OAC) alone for secondary prevention of IS. In a large prospective cohort of patients with acute IS and atrial fibrillation, we determine the association between antithrombotic regimen on discharge and risk of major vascular events.
Methods:
Prospective cohort of consecutive patients included in the Ontario Stroke Registry. Multivariable Cox proportional hazard models were used to determine the association between antithrombotic regimen on discharge and time to death or admission for recurrent IS, myocardial infarction, or major bleeding.
Results:
Two thousand one hundred sixty-two patients were hospitalized atrial fibrillation and acute IS. At discharge, 8.0% were prescribed no antithrombotic therapy, 21.6% antiplatelet therapy alone, 39.3% OAC (warfarin) alone, and 31.1% combination OAC and antiplatelet therapy. Compared with OAC alone (hazard ratio [HR], 1.0), no antithrombotic therapy (HR, 1.51; 95% confidence interval, 1.23-1.86) and antiplatelet therapy (HR, 1.31; 95% confidence interval, 1.14-1.50) were associated with an increased risk of the primary composite outcome, whereas combination OAC and antiplatelet therapy was associated with a trend toward a reduced risk (HR, 0.91; 95% confidence interval, 0.80-1.04 overall and HR, 0.79; 95% confidence interval, 0.61-1.02 in those with coronary heart disease). Results were consistent in those with severe stroke: HR 1.58 (95% CI, 1.21-2.06), 1.34 (95% CI, 1.09-1.63), and 0.91 (95% CI, 0.74-1.11), respectively.
Conclusions:
Contrary to current guidelines, 30% of patients with atrial fibrillation and recent IS are not prescribed any OAC therapy on discharge, whereas a further 30% are prescribed combination OAC and antiplatelet therapy. Combination OAC and antiplatelet therapy in patients at high cardiovascular risk requires evaluation in clinical trials, particularly with the newer OACs, given their more favorable risk-benefit ratio compared with warfarin.
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