High frequency of anticoagulation management errors preceding ischaemic strokes in atrial fibrillation

Area of Science:

• Cardiology
• Neurology
• Pharmacology

Background:

• Anticoagulants are crucial for preventing cardioembolic stroke in atrial fibrillation (AF) patients.
• Management errors and suboptimal use of anticoagulants, including aspirin, are prevalent globally, particularly with vitamin K antagonists.
• The advent of non-vitamin K oral anticoagulants (NOACs) offers new therapeutic options but requires careful management.

Purpose of the Study:

• To determine the incidence of anticoagulant mismanagement errors in patients admitted with ischemic stroke and a history of AF.
• To identify clinical factors associated with stroke outcomes in the context of anticoagulant management.
• To evaluate the impact of anticoagulant mismanagement on mortality in the era of NOACs.

Main Methods:

• A retrospective analysis was conducted on 306 patients with AF and ischemic stroke admitted to a tertiary hospital stroke unit.
• Data were collected between January 2016 and June 2019.
• Management errors were assessed using European Heart Rhythm Association criteria, focusing on anticoagulation use in the two weeks prior to the index stroke.

Main Results:

• A significant majority (64%) of patients experienced anticoagulant management errors.
• Patients with errors were older and more frequently female.
• Among those with errors, 37% were not prescribed anticoagulation despite high stroke risk and no contraindications, and 20% had anticoagulation inappropriately stopped.
• Mortality at 3 months was substantially higher (32%) in the mismanagement group compared to the appropriately anticoagulated group (17%).

Conclusions:

• Inappropriate anticoagulant management is a widespread issue preceding acute ischemic stroke in AF patients.
• This mismanagement is strongly associated with increased mortality.
• Optimizing anticoagulant practices holds significant potential for reducing stroke incidence in the AF population.