Socioeconomic Inequalities in the Prescription of Oral Anticoagulants in Stroke Patients With Atrial Fibrillation

Genetic testing in early-onset atrial fibrillation

Atrial fibrillation (AF) is a globally prevalent cardiac arrhythmia with significant genetic underpinnings, as highlighted by recent large-scale genetic studies. A prominent clinical and genetic overlap exists between AF, heritable ventricular cardiomyopathies, and arrhythmia syndromes, underlining the potential of AF as an early indicator of severe ventricular disease in younger individuals. Indeed, several recent studies have demonstrated meaningful yields of rare pathogenic variants among early-onset AF patients (∼4%-11%), most notably for cardiomyopathy genes in which rare variants are considered clinically actionable. Genetic testing thus presents a promising opportunity to identify monogenetic defects linked to AF and inherited cardiac conditions, such as cardiomyopathy, and may contribute to prognosis and management in early-onset AF patients. A first step towards recognizing this monogenic contribution was taken with the Class IIb recommendation for genetic testing in AF patients aged 45 years or younger by the 2023 American College of Cardiology/American Heart Association guidelines for AF. By identifying pathogenic genetic variants known to underlie inherited cardiomyopathies and arrhythmia syndromes, a personalized care pathway can be developed, encompassing more tailored screening, cascade testing, and potentially genotype-informed prognosis and preventive measures. However, this can only be ensured by frameworks that are developed and supported by all stakeholders. Ambiguity in test results such as variants of uncertain significance remain a major challenge and as many as ∼60% of people with early-onset AF might carry such variants. Patient education (including pretest counselling), training of genetic teams, selection of high-confidence genes, and careful reporting are strategies to mitigate this. Further challenges to implementation include financial barriers, insurability issues, workforce limitations, and the need for standardized definitions in a fast-moving field. Moreover, the prevailing genetic evidence largely rests on European descent populations, underscoring the need for diverse research cohorts and international collaboration. Embracing these challenges and the potential of genetic testing may improve AF care. However, further research-mechanistic, translational, and clinical-is urgently needed.

Social drivers in atrial fibrillation occurrence, screening, treatment, and outcomes: systematic-narrative hybrid review

The importance of social drivers of health (SDOH) in the occurrence, detection, treatment, and outcome of atrial fibrillation (AF) has attracted increasing attention. Addressing SDOH factors may suggest opportunities to prevent AF and its complications. We aimed to conduct a structured narrative review and summarize current knowledge on the association between race and ethnicity, SDOH, including rural vs. urban habitation, education, income, and neighbourhood, and the risk of AF, its management, and complications. We identified 537 references in PubMed and 473 references in Embase. After removal of duplicates, we screened the abstracts of 975 references, resulting in 113 references that were examined for eligibility. Subsequently, 34 references were excluded leaving 79 references for the review. Evidence of a social gradient in AF incidence and prevelance were conflicting. However, we found substantial evidence indicating social inequities in the detection of AF, access to treatment, and outcomes such as healthcare utilization, bleeding, heart failure, stroke, dementia, work disability, and death. Inequities are reported across various health care systems and constitute a global problem affecting several continents, although data from Africa and South America are lacking. Given the documented social inequities in AF detection, management, and outcomes, there is an urgent need for healthcare systems, policymakers, and society to identify and implement effective interventions that can reduce inequities and improve outcomes in individuals with AF.

Trends of Sex Differences and Associated Factors in Stroke Outcomes Among Patients With Acute Ischemic Stroke: 2007 to 2018

BACKGROUND AND OBJECTIVES

Female patients have been shown to experience worse clinical outcomes after acute ischemic stroke (AIS) compared with male patients. We aimed to estimate the temporal trends in the sex differences in stroke outcomes and identify risk factors contributing to the sex differences spanning 10 years in China.

METHODS

This cohort study was conducted based on data from the China National Stroke Registries (CNSRs, comprising 3 phases, I-III, from 2007 to 2018). Patients with ischemic stroke within 7 days of symptom onset were included. The primary outcome was a 12-month poor functional outcome. Other outcomes included mortality and disability-adjusted life-year (DALY) lost. The sex differences in outcomes and associated factors were estimated using multivariable logistic regression. The sex differences between CNSRs were tested by the interaction of sex and time.

RESULTS

Among 42,564 patients included, 35.4% were female. The age-adjusted event rate of 12-month poor functional outcome and mortality decreased both in male and female patients after stroke onset (CNSRs I, II, and III, all p varies over time <0.001). There was a decrease in DALY lost for both sexes over the decade (male patients: from 10.1 to 9.3 DALYs; female patients: from 10.9 to 9.6 DALYs). Female patients showed worse 12-month poor functional outcome in CNSRs I and II (odds ratio [OR] with 95% CI: 1.24 [1.10-1.39] and 1.12 [1.01-1.25], respectively) compared with male patients, but the sex difference attenuated in CNSR III (OR with 95% CI: 1.02 [0.89-1.16]), with the temporal trend (p varies over time = 0.004). The sex difference and the temporal trend of the sex difference in mortality from 2007 to 2018 were not found (p varies over time = 0.45). The most important factors attenuating the sex difference in poor functional outcome in CNSRs I and III were education level, socioeconomic deprivation, baseline stroke severity, and current smoking.

DISCUSSION

This study demonstrated that the sex disparity in poor functional outcome at 12 months was substantially narrowed covering 10 years and completely attenuated in 2015-2018. The findings suggested that female patients have experienced larger improvements in stroke outcomes than male patients over the past decade.

Mediation Analyses of the Mechanisms by Which Socioeconomic Status, Comorbidity, Stroke Severity, and Acute Care Influence Stroke Outcome

BACKGROUND AND OBJECTIVES

Low socioeconomic status (SES) is associated with increased risk of death and disability after stroke, but interventional targets to minimize disparities remain unclear. We aim to assess the extent to which SES-based disparities in the association between low SES and death and dependency at 3 months after stroke could be eliminated by offsetting differences in comorbidity, stroke severity, and acute care.

METHODS

This nationwide register-based cohort study included all 72 hospitals caring for patients with acute stroke in Sweden. All patients registered with an acute ischemic stroke in the Swedish Stroke Register in 2015-2016 who were independent in activities of daily living (ADL) during stroke were included. Data on survival and SES the year before stroke were retrieved by cross-linkage with other national registers. SES was defined by education and income and categorized into low, mid, and high. Causal mediation analysis was used to study the absolute risk of death and ADL dependency at 3 months depending on SES and to what extent hypothetical interventions on comorbidities, stroke severity, and acute care would equalize outcomes.

RESULTS

Of the 25,846 patients in the study, 6,798 (26.3%) were dead or ADL dependent 3 months after stroke. Adjusted for sex and age, low SES was associated with an increased absolute risk of 5.4% (95% CI 3.9%-6.9%; p < 0.001) compared with mid SES and 10.1% (95% CI 8.1%-12.2%; p < 0.001) compared with high SES. Intervening to shift the distribution of all mediators among patients with low SES to those of the more privileged groups would result in absolute reductions of these effects by 2.2% (95% CI 1.2%-3.2%; p < 0.001) and 4.0% (95% CI 2.6%-5.5%; p < 0.001), respectively, with the largest reduction accomplished by equalizing stroke severity.

DISCUSSION

Low SES patients have substantially increased risks of death and ADL dependency 3 months after stroke compared with more privileged patient groups. This study suggests that if we could intervene to equalize SES-related differences in the distributions of comorbidity, acute care, and stroke severity, up to 40 of every 1,000 patients with low SES could be prevented from dying or becoming ADL dependent.

Association of Neighborhood Disadvantage and Anticoagulation for Patients with Atrial Fibrillation in the Veterans Health Administration: the REACH-AF Study

BACKGROUND

Atrial fibrillation (AF) is a common arrhythmia, the management of which includes anticoagulation for stroke prevention. Although disparities in anticoagulant prescribing have been well documented for individual socioeconomic factors, less is known about the association of neighborhood-level disadvantage and anticoagulation for AF.

OBJECTIVE

To assess the association between neighborhood disadvantage and anticoagulant initiation for patients with incident AF.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A cohort of patients enrolled in the Veterans Health Administration (VA) with incident AF from January 2014 through December 2020 from the Race, Ethnicity, and Anticoagulant CHoice in Atrial Fibrillation (REACH-AF) Study.

MAIN MEASURES

The primary exposure was neighborhood disadvantage quantified using area deprivation index (ADI), classified by quintiles (Q). The outcomes were initiation of any anticoagulant therapy (warfarin or direct oral anticoagulant, DOAC) within 90 days of AF diagnosis and DOAC use among initiators. We used mixed effects logistic regression to assess the association between ADI and anticoagulant therapy, incorporating a fixed effect for treatment site and baseline patient, provider, and facility covariates.

KEY RESULTS

Among 161,089 patients, 105,489 (65.5%) initiated any anticoagulant therapy, and 78,903 (74.8%) used DOACs. Any anticoagulant therapy increased 3.2 percentage points (63.0% to 66.2%; p<.001) from Q1 to Q5, whereas DOAC use decreased 8.2 percentage points (79.4% to 71.2%; p<.0001) across quintiles. The adjusted odd ratios of any anticoagulant therapy were non-significantly different for Q2-Q5 than Q1. The adjusted odds of DOAC use decreased progressively from 0.89 (95% CI, 0.84-0.94) in Q2 to 0.77 (95% CI, 0.73-0.83) in Q5 compared to Q1 (p<.0001).

CONCLUSIONS

Among Veterans with incident AF, we observed similar initiation of any anticoagulant, though neighborhood deprivation was associated with decreased DOAC use among anticoagulant initiators. Future interventions to improve pharmacoequity in anticoagulant prescribing for AF should consider the role of neighborhood-level determinants of health inequities.

The impact of regional deprivation on stroke incidence, treatment, and mortality in Germany

BACKGROUND

Regional deprivation has been shown to be an influential factor in stroke incidence risk. However, there is a paucity of knowledge on regional differences in stroke incidence and mortality in Germany.

METHODS

We assessed data from the Diagnosis Related Groups statistics (2016-2019) and the German Federal Registry of Physicians (2019). Negative binomial regression analysis was used to examine the association between the German Index of Multiple Deprivation 2015 covering 401 districts and district-free cities in Germany and stroke incidence, treatment, and mortality.

RESULTS

The adjusted rate ratios of stroke incidence and mortality with the highest deprivation level compared with the least deprived area were 1.161 (95% CI [1.143, 1.179]) and 1.193 (95% CI [1.148, 1.239]), respectively. Moreover, this study revealed that physician density was higher in district-free cities compared to districts.

CONCLUSIONS

Our results indicate that regional deprivation is associated with incident and mortality cases of stroke, necessitating a more targeted approach to stroke prevention in deprived regions.

Socioeconomic status and stroke severity: Understanding indirect effects via risk factors and stroke prevention using innovative statistical methods for mediation analysis

Background

Those with low socioeconomic status have an increased risk of stroke, more severe strokes, reduced access to treatment, and more adverse outcomes after stroke. The question is why these differences are present. In this study we investigate to which extent the association between low socioeconomic status and stroke severity can be explained by differences in risk factors and stroke prevention drugs.

Methods

The study included 86 316 patients registered with an ischemic stroke in the Swedish Stroke Register (Riksstroke) 2012–2016. Data on socioeconomic status was retrieved from the Longitudinal integrated database for health insurance and labour market studies (LISA) by individual linkage. We used education level as proxy for socioeconomic status, with primary school education classified as low education. Stroke severity was measured using the Reaction Level Scale, with values above 1 classified as severe strokes. To investigate the pathways via risk factors and stroke prevention drugs we performed a mediation analysis estimating indirect and direct effects.

Results

Low education was associated with an excess risk of a severe stroke compared to mid/high education (absolute risk difference 1.4%, 95% CI: 1.0%-1.8%), adjusting for confounders. Of this association 28.5% was an indirect effect via risk factors (absolute risk difference 0.4%, 95% CI: 0.3%-0.5%), while the indirect effect via stroke prevention drugs was negligible.

Conclusion

Almost one third of the association between low education and severe stroke was explained by risk factors, and clinical effort should be taken to reduce these risk factors to decrease stroke severity among those with low socioeconomic status.

American Journal of Preventive Cardiology: Area Deprivation Index and Oral Anticoagulation in New Onset Atrial Fibrillation

Objective

Oral anticoagulation is a standard of care for thromboembolic stroke prevention in individuals with atrial fibrillation (AF). Social determinants of health have had limited investigation in AF and particularly in access to anticoagulation. We examined the relation between area deprivation index (ADI) and anticoagulation in individuals at risk of stroke due to AF.

Methods

We conducted a retrospective analysis of patients with incident, non-valvular AF from 2015-2020 receiving care at a large, regional health center. We extracted demographics, medications, and problem lists and used administrative coding to identify comorbid conditions and relevant covariates, and individual-level residential address to ascertain ADI. We examined the relation between ADI and receipt of prescribed oral anticoagulation (warfarin or direct-acting oral anticoagulant, or DOAC) at 90 days following AF diagnosis in multivariable-adjusted models.

Results

Following exclusions, the dataset included 20,210 individuals (age 74.5±10.9 years; 51% women; 94% white race). In multivariable-adjusted analyses, individuals in the highest quartile of ADI had a 16% lower likelihood of receiving anticoagulation prescription than those in the lowest ADI quartile (Odds Ratio [OR] 0.84; 95% Confidence Interval [CI], 0.75-0.95) at 90 days following AF diagnosis. In those receiving anticoagulation, individuals in the highest ADI quartile had a 24% lower likelihood of receiving a DOAC prescription as opposed to warfarin prescription than those in the lowest quartile (OR 0.76; 95% CI, 0.60-0.96) at 90 days following AF diagnosis.

Conclusions

We demonstrate the association of higher neighborhood deprivation as determined by ADI with decreased likelihood of (1) anticoagulation prescribing for stroke prevention in AF and (2) prescription of a DOAC when any oral anticoagulation is prescribed. Our results suggest neighborhood-based health inequities in the receipt of anticoagulation prescription for stroke prevention in AF in a large, regional health care system.

Sex and Economic Disparity Related to Reperfusion Therapies for Patients with Acute Ischemic Stroke in South Korea across a 10-Year Period: A Nationwide Population-Based Study Using the National Health Insurance Database

A complete enumeration study was conducted to evaluate trends related to reperfusion therapies (intravenous thrombolysis (IVT) and endovascular treatment (EVT)) in acute ischemic stroke (AIS) in South Korea, according to sex, economic status, and age, over a 10-year period retrospectively, using the National Health Information Database (NHIS-2020-1-481). This study included AIS patients aged ≥20 years who were hospitalized in a general hospital or tertiary hospital for ≥4 days and underwent brain imaging during the same period. Study participants were classified by sex, economic status (Medical Aid beneficiaries and National Health Insurance beneficiaries) and age (20-44, 45-64, 65-79, and ≥80 years). Women showed a significantly lower OR (Odds ratio) than men in IVT (OR: 0.75; 95% CI: 0.73-0.77), EVT (OR: 0.96; 95% CI: 0.93-0.99), and any therapy (OR: 0.82; 95% CI: 0.80-0.84). The Medical Aid beneficiaries showed significantly lower OR in IVT (OR 0.91, 95% CI 0.88-0.95), EVT (OR 0.93, 95% CI 0.89-0.98), and either therapy (OR 0.92, 95% CI 0.90-0.95) than the National Health Insurance beneficiaries. This study showed sex and economic disparity related to reperfusion therapies in patients with AIS in Korea.

Gender and Socioeconomic Inequality in the Prescription of Direct Oral Anticoagulants in Patients with Non-Valvular Atrial Fibrillation in Primary Care in Catalonia (Fantas-TIC Study)

Background: Evidence points to unequal access to direct oral anticoagulant (DOAC) therapy, to the detriment of the most socioeconomically disadvantaged patients in different geographic areas; however, few studies have focused on people with atrial fibrillation. This study aimed to assess gender-based and socioeconomic differences in the prescriptions of anticoagulants in people with non-valvular atrial fibrillation who attended Primary Care. Method: A cross-sectional study with real-world data from patients treated in Primary Care in Catalonia (Spain). Data were obtained from the SIDIAP database, covering 287 Primary Care centers in 2018. Results were presented as descriptive statistics and odds ratios estimated by multivariable logistic regression. Results: A total of 60,978 patients on anticoagulants for non-valvular atrial fibrillation were identified: 41,430 (68%) were taking vitamin K antagonists and 19,548 (32%), DOACs. Women had higher odds of treatment with DOAC (adjusted odds ratio [ORadj] 1.12), while lower DOAC prescription rates affected patients from Primary Care centers located in high-deprivation urban centers (ORadj 0.58) and rural areas (ORadj 0.34). Conclusions: DOAC prescription patterns differ by population. Women are more likely to receive it than men, while people living in rural areas and deprived urban areas are less likely to receive this therapy. Following clinical management guidelines could help to minimize the inequality.

Socioeconomic status and lifestyle in young ischaemic stroke patients: a possible relationship to stroke recovery and risk of recurrent event

OBJECTIVES

Socioeconomic status (SES) and lifestyle have impact on recovery after ischaemic stroke (IS) and on risk of recurrent ischaemic stroke (RIS) in elderly patients. With regard to currently available limited data on young people, we aimed to assess SES and parameters of lifestyle and evaluate their relationship to stroke recovery and risk of RIS in young patients.

METHODS

We analysed consecutive young IS patients < 50 years enrolled in the prospective HISTORY (Heart and Ischaemic STrOke Relationship studY) study registered on ClinicalTrials.gov (NCT01541163). Data were acquired from structured a self-evaluating multiple-choice questionnaire. Clinical outcome was assessed using the Modified Rankin Scale (MRS) after 3 months with score 0-1 for excellent outcome.

RESULTS

Data were obtained from 297 (163 males, mean age 39.6 ± 7.8 years) young patients. Patients with MRS 0-1 (237, 79.8%) did not differ in SES except university education (21.1 vs. 3.3%; p = 0.001), less smoked (16.5 vs. 58.3%; p < 0.001), more of them did regular sport activities (79.1 vs. 51.6%; p = 0.02) and passed regular preventive medical checks (45.6 vs. 24.2%; p = 0.01). Twelve (4%) patients suffered from RIS during a follow-up with median of 25 months. They did not differ in SES but had higher body mass index (31.6 vs. 26.7; p = 0.007), reported less regular sport activities (16.7 vs. 73.0%; p < 0.001) and less regular medical checks (8.3 vs. 40.0%; p = 0.001).

CONCLUSION

In young patients, SES had no relationship to clinical outcome after IS and to risk of RIS except education level. Some parameters of health lifestyle were presented more in patients with excellent outcome and without RIS during the follow-up.

A Score of Low-Grade Inflammation for Predicting Stroke Recurrence in Patients with Ischemic Stroke

Background and Purpose

The impact of low-grade inflammation (LGI) on stroke recurrence has not been well studied yet. We aimed to evaluate the association between LGI and stroke recurrence in patients with ischemic stroke.

Methods

Patients with first-ever ischemic stroke diagnosed within 72 hours of symptoms onset were consecutively recruited from the Nanjing Stroke Registry Program. C-reactive protein (CRP) level, white blood cell (WBC) count, platelet (PLT) count, and neutrophil-to-lymphocyte ratio (NLR) were conceived as low-grade inflammation biomarkers and combined into a standardized LGI score. The association of LGI score with the risk of stroke recurrence was analyzed with multivariate Cox regression models. Analyses accounting for the competing risk of stroke recurrence and death were also performed.

Results

Of the 1214 patients studied (median age, 61 years; male, 71.6%), 177 (14.6%) patients experienced a recurrent stroke with a median follow-up of 23.0 (interquartile ranges, 14.5-34.0) months. Patients with stroke recurrence had a higher LGI score (median, 3 versus -2; P < 0.001) than those without recurrence. The univariate analysis indicated that patients with LGI scores in the fourth quartile were more likely to have a stroke recurrence (hazard ratios [HR], 4.312; 95% confidence interval [CI], 2.675-6.952; P < 0.001). After adjusting for potential confounders, the association remained significant in the multivariate Cox regression model (HR, 4.080; 95% CI, 2.420-6.879; P < 0.001). Competing risks model and sensitivity analysis further confirmed this conclusion.

Conclusion

This study showed that an elevated LGI score was associated with a higher risk of stroke recurrence, independent of other vascular risk factors.

Regional Deprivation, Stroke Incidence, and Stroke Care

BACKGROUND

Regional deprivation can increase the risk of illness and adversely affect care outcomes. In this study, we investigated for the German state of Rhineland-Palatinate whether spatial-structural disadvantages are associated with an increased frequency of ischemic stroke and with less favorable care outcomes.

METHODS

We compared billing data from DRG statistics (2008-2017) and quality assurance data (2017) for acute ischemic stroke with the German Index of Multiple Deprivation 2010 (GIMD 2010) for the 36 districts (Landkreise) and independent cities (i.e., cities not belonging to a district) in Rhineland-Palatinate using correlation analyses, a Poisson regression analysis, and logistic regression analyses.

RESULTS

The age-standardized stroke rates (ASR) ranged from 122 to 209 per 100 000 inhabitants, while the GIMD 2010 ranged from 4.6 to 47.5; the two values were positively correlated (Spearman's ρ = 0.47; 95% confidence interval [0.16; 0.85]). In 2017, mechanical thrombectomies were performed more commonly (5.7%) in the first GIMD 2010 quartile of the regional areas (i.e., in the least deprived areas) than in the remaining quartiles (4.2-4.6%). The intravenous thrombolysis rates showed no differences from one GIMD 2010 quartile to another. Severe neurological deficits (National Institutes of Health Stroke Scale ≥ 5) on admission to the hospital were slightly more common in the fourth quartile (i.e., in the most deprived areas), while antiplatelet drugs and statins were somewhat less commonly ordered on discharge in those areas than in the first quartile.

CONCLUSION

These findings document a relationship between regional deprivation and the occurrence of acute ischemic stroke. Poorer GIMD 2010 scores were associated with worse care outcomes in a number of variables, but the absolute differences were small.

Evaluating the effects of socioeconomic status on stroke and bleeding risk scores and clinical events in patients on oral anticoagulant for new onset atrial fibrillation

Background

The risk of thromboembolism and bleeding before initiation of oral anticoagulant (OAC) in atrial fibrillation patients is estimated by CHA₂DS₂-VASc and HAS-BLED scoring system, respectively. Patients’ socioeconomic status (SES) could influence these risks, but its impact on the two risk scores’ predictive performance with respect to clinical events remains unknown. Our objective was to determine if patient SES defined by area deprivation index (ADI), in conjunction with CHA₂DS₂-VASc and HAS-BLED scores, could guide oral anticoagulation therapy.

Methods and findings

The study cohort included newly diagnosed patients with AF who were treated with warfarin. The cohort was stratified by the time in therapeutic range of INR (TTR), ADI, CHA₂DS₂-VASc, and HAS-BLED risk scores. TTR and ischemic and bleeding events during the first year of therapy were compared across subpopulations. Among 7274 patients, those living in the two most deprived quintiles (ADI ≥60%) had a significantly higher risk of ischemic events and those in the most deprived quintile (ADI≥80%) had a significantly increased risk of bleeding events. ADI significantly improved the predictive performance of CHA₂DS₂-VASc but not HAS-BLED risk scores.

Conclusion

ADI can predict increased risk for ischemic and bleeding events in the first year of warfarin therapy in patients with incident AF.

The efficacy and safety of Hirudin plus Aspirin versus Warfarin in the secondary prevention of Cardioembolic Stroke due to Nonvalvular Atrial Fibrillation: A multicenter prospective cohort study

Background: To investigate the efficacy and safety of hirudin plus aspirin therapy compared with warfarin in the secondary prevention of cardioembolic stroke due to nonvalvular atrial fibrillation (NVAF). Methods: Patients with cardioembolic stroke due to NVAF were prospectively enrolled from 18 collaborating hospitals from Dec 2011 to June 2015. Fourteen days after stroke onset, eligible patients were assigned to the hirudin plus aspirin group (natural hirudin prescribed as the traditional Chinese medicine Maixuekang capsule, 0.75 g, three times daily, combined with aspirin 100 mg, once daily) or the warfarin group (dose-adjusted warfarin targeting international normalized ratio (INR) 2-3, with an initial daily dose of 1.25 mg). Patients were followed up at 1, 2, 3, 6, 9, and 12 months after stroke onset. Time in therapeutic range (TTR) was calculated according to Rosendaal methodology to evaluate the quality of INR management in the warfarin group. The primary efficacy endpoint was the recurrence of stroke within 12 months after stroke onset. Safety was assessed as the occurrence of the composite event "intracranial hemorrhage and other bleeding events, death, and other serious adverse events". The Cox proportional hazard model and Kaplan-Meier curve were used to analyze the efficacy and safety events. Results: A total of 221 patients entered final analysis with 112 patients in the hirudin plus aspirin group and 109 in the warfarin group. Over the whole duration of our study, TTR for patients taking warfarin was 66.5 % ± 21.5%. A significant difference was not observed in the recurrence of stroke between the two groups (3.57% vs. 2.75%; P = 0.728). The occurrence of safety events was significantly lower in the hirudin plus aspirin group (2.68% vs.10.09%; P = 0.024). The risk for efficacy event was similar between the two groups (hazard ratio (HR), 1.30; 95% confidence interval (CI), 0.29-5.80). The safety risk was significantly lower in the hirudin plus aspirin group (HR, 0.27; 95% CI, 0.07-0.95). Kaplan-Meier analysis revealed significant difference in the temporal distribution in safety events (P = 0.023) but not in stroke recurrence (P = 0.726). Conclusion: Significant difference in efficacy was not detected between warfarin group and hirudin plus aspirin group. Compared with warfarin, hirudin plus aspirin therapy had lower safety risk in the secondary prevention of cardioembolic stroke due to NVAF.

Long-Term Effect of Income Level on Mortality after Stroke: A Nationwide Cohort Study in South Korea

We investigated whether income level has long-term effects on mortality rate in stroke patients and whether this varies with time after the first stroke event, using the National Health Insurance Service National Sample Cohort data from 2002 to 2015 in South Korea. The study population was new-onset stroke patients ≥18 years of age. Patients were categorized into Category (1) insured employees and Category (2) insured self-employed/Medical Aid beneficiaries. Each category was divided into three and four income level groups, retrospectively. The study population comprised of 11,668 patients. Among the Category 1 patients (n = 7720), the low-income group's post-stroke mortality was 1.15-fold higher than the high-income group. Among the Category 2 patients (n = 3948), the lower income groups had higher post-stroke mortality than the high-income group (middle-income, aOR (adjusted odds ratio) 1.29; low-income, aOR 1.70; Medical Aid beneficiaries, aOR 2.19). In this category, the lower income groups' post-stroke mortality risks compared to the high-income group were highest at 13-36 months after the first stroke event(middle-income, aOR 1.52; low-income, aOR 2.31; Medical Aid beneficiaries, aOR 2.53). Medical Aid beneficiaries had a significantly higher post-stroke mortality risk than the high-income group at all time points.

Antithrombotic Preventive Medication Prescription Redemption and Socioeconomic Status in Hungary in 2016: A Cross-Sectional Study

This work was designed to investigate antithrombotic drug utilization and its link with the socioeconomic characteristics of specific population groups in Hungary by a comparative analysis of data for prescriptions by general practitioners and the redeemed prescriptions for antithrombotic drugs. Risk analysis capabilities were applied to estimate the relationships between socioeconomic status, which was characterized by quintiles of a multidimensional composite indicator (deprivation index), and mortality due to thromboembolic diseases as well as antithrombotic medications for the year 2016 at the district level in Hungary. According to our findings, although deprivation is a significant determinant of mortality due to thromboembolic diseases, clusters can be identified that represent exemptions to this rule: an eastern part of Hungary, consisting of two highly deprived counties, had significantly lower mortality than the country average; by contrast, the least-deprived northwestern part of the country, consisting of five counties, had significantly higher mortality than the country average. The fact that low socioeconomic status in general and poor adherence to antithrombotic drugs irrespective of socioeconomic status were associated with increased mortality indicates the importance of more efficient control of preventive medication and access to healthcare in all districts of the country to reduce mortality due to thromboembolic diseases.

Temporal trends of atrial fibrillation and/or rheumatic heart disease-related ischemic stroke, and anticoagulant use in Chinese population: An 8-year study

BACKGROUND AND PURPOSE

Underuse of anticoagulants in ischemic stroke patients with atrial fibrillation (AF) and/or rheumatic heart disease (RHD) is a global concern, especially in China. However, the extent to which anticoagulants are underused in AF and/or RHD-related ischemic stroke in China has not been well characterized. We aimed to explore the temporal trends of AF and/or RHD-related ischemic stroke patients, anticoagulation use and factors related to suboptimal use of anticoagulants in a Chinese population.

METHODS

Acute ischemic stroke patients admitted to department of neurology, West China hospital, Sichuan university were included from January 1st 2010 to December 31st 2017. Temporal trends of AF and RHD related ischemic strokes were compared over 2 year epochs (2010-2011, 2012-2013, 2014-2015 and 2016-2017). Multivariable logistic regression models were performed to evaluate the variables associated with non-anticoagulants at discharge.

RESULTS

Of 4357 acute ischemic stroke patients (≤7 days after onset) included between 2010 and 2017, 823(18.9%) were AF and/or RHD-related. Over the 8 years, the proportion of RHD-ischemic stroke decreased significantly from 7.8% in 2010-2011 to 4.5% in 2016-2017, whereas no reduction in AF-ischemic stroke was observed. There was an increase in the proportion of AF and/or RHD patients who were prescribed anticoagulants at discharge (from 26.4% to 45.1%, P for trend<0.001), while the proportion given antiplatelet therapy decreased with time (from 56.0% to 30.0%, P for trend<0.001). The use of non-vitamin K antagonist oral anticoagulants (NOAC) use at discharge remained low during the study period (2.1%).Older age (per 5 years increase, OR 1.91, 95% CI 1.28-2.86), higher NIHSS score on admission(OR 1.08, 95% CI 1.05-1.11), the presence of non-symptomatic hemorrhagic transformation(OR 2.54, 95% CI 1.67-3.94) and symptomatic hemorrhagic transformation(OR 3.04, 95% CI 1.14-9.73) were independently associated with non-anticoagulant use at discharge. However, patients with a prior diagnosis of AF/RHD and anticoagulation before admission were more likely to receive anticoagulants at discharge.

CONCLUSIONS

In an ischemic stroke population in China we found an increasing but still low use of anticoagulation. Further research is required on how to improve anticoagulation use at discharge in ischemic stroke patients, including access to NOAC's.

Stroke in Women

PURPOSE OF REVIEW

This article reviews sex differences in stroke risk and presentation, with a particular emphasis on the unique risk factors women experience throughout the lifespan.

RECENT FINDINGS

Although prior studies suggested women have worse outcomes after stroke, it is now clear that age, prestroke functional status, and comorbidities explain many of the differences between men and women in stroke severity, functional outcomes, and mortality. Several meta-analyses and large cohort studies have evaluated the risk factors for women related to reproductive factors and found that fewer years between menarche and menopause, pregnancy complications (preeclampsia/eclampsia, preterm delivery, and stillbirth), oophorectomy, hormone replacement therapy use, and younger age at menopause all increase the risk of stroke. Although the nonreproductive risks of stroke overlap between men and women, those with greater impact on women include age, hypertension, atrial fibrillation, socioeconomic status, and depression.

SUMMARY

Significant sex differences are observed in risk factors of stroke and stroke outcome. Including this information in the clinical assessment of the individual patient may support development of more effective prevention plans.

Rate and Determinants of Recurrence at 1 Year and 5 Years After Stroke in a Low-Income Population in Rural China

Recurrent stroke is becoming an increasingly important public health issue owing to the increased risk of disability and death. However, population-based studies investigating the rate of recurrent stroke in China are rare. We explored the rate and determinants of recurrent stroke within 1 and 5 years after the initial stroke in a rural population in China. Data for stroke events were obtained from the Tianjin Brain Study, conducted between 1992 and 2016. The age-standardized rates of recurrent stroke within the first year and the first 5 years after the initial stroke were calculated for this period. Determinants of recurrent stroke were assessed using Cox regression analyses. The overall age-standardized rate of recurrent stroke within 1 year was 5.7% (men, 6.9%; women, 4.6%); within 5 years, the overall recurrent stroke rate was 22.5% (men, 24.0%; women, 20.2%). The recurrence rate increased with advancing age and decreased with increased educational attainment. Age ≥65 years and a history of alcohol consumption were independent risk factors for recurrent stroke within 1 year after the incident stroke, after adjusting for age, sex, education, hypertension, diabetes, smoking, and alcohol consumption. However, the risk of recurrent stroke within 5 years after the incident stroke was positively associated with male sex, age ≥65 years, a lower level of education, known diabetes, and alcohol consumption, after adjusting for the previously indicated covariates. These findings suggest a crucial need to address risk factor management among stroke patients to reduce the burden of stroke, especially among low-income populations. Furthermore, a multicenter, large sample, nationwide study is urgently needed.

Annual rate of newly treated atrial fibrillation by age and gender in France, 2010-2016

Few studies are available on atrial fibrillation (AF) burden at a whole country scale. The objective was to estimate the rate of AF patients newly treated with oral anticoagulants (OAC) in France each year between 2010 and 2016 and to describe age and gender differences. We used the French national health data system. For each year between 2010 and 2016, we identified patients aged over 20 initiating OAC. OAC indicated for the treatment of AF was determined by hospitalization diagnoses, specific procedures and registered long-term disease status, or a multiple imputation process for patients with no recorded information as to why they initiated OAC. Among the 421,453 individuals initiating OAC treatment in 2016, the estimated number of newly treated AF patients was 210,131, women accounting for 46%, patients under 65 years old 17%, and 21.4% of patients living in most deprived area. Age-standardized rates reached 400/100,000 inhabitants. Approximately 19% of patients were recently hospitalized for heart failure and 7% for stroke. Age-standardized rates increased by 35% over the study period in both genders, with a marked increase in patients under 55 (+ 41%) and those over 85 years old (+ 60%). Annual rates of AF patients newly treated with OAC increased by 35% between 2010 and 2016. Important differences in rates were observed according to age, gender and the deprivation level of the living area.

Short-term and long-term case-fatality rates for myocardial infarction and ischaemic stroke by socioeconomic position and sex: a population-based cohort study in Sweden, 1990-1994 and 2005-2009

OBJECTIVE

Case-fatality rates (CFRs) for myocardial infarction (MI) and ischaemic stroke (IS) have decreased over time due to better prevention, medication and hospital care. It is unclear whether these improvements have been equally distributed according to socioeconomic position (SEP) and sex. The aim of this study is to analyse differences in short-term and long-term CFR for MI and IS by SEP and sex between the periods 1990-1994 to 2005-2009 for the entire Swedish population.

DESIGN

Population-based cohort study based on Swedish national registers.

METHODS

We used logistic regression and flexible parametric models to estimate short-term CFR (death before reaching the hospital or on the disease event day) and long-term CFR (1 year case-fatality conditional on surviving short-term) across five distinct SEP groups, as well as CFR differences (CFRDs) between SEP groups for both MI and IS from 1990-1994 to 2005-2009. : Result S: Overall short-term CFR for both MI and IS decreased between study periods. For MI, differences in short-term and long-term CFR between the least and most favourable SEP group were generally stable, except in long-term CFR among women; intermediate SEP groups mostly managed to catch up with the most favourable SEP group. For IS, short-term CFRD generally decreased compared with the most favourable group; but long-term CFRD were mostly stable, except for an increase for older subjects.

CONCLUSION

Despite a general decline in CFR for MI and IS across all SEP groups and both sexes as well as some reductions in CFRD, we found persistent and even increasing CFRD among the least advantaged SEP groups, older patients and women. We speculate that targeted prevention rather than treatment strategies have the potential to reduce these inequalities.

Nurse-led, telephone-based secondary preventive follow-up benefits stroke/TIA patients with low education: a randomized controlled trial sub-study

BACKGROUND

The objective of this study was to analyze the impact of two forms of secondary preventive follow-up on the association between education level and levels of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) after stroke/transient ischemic attack (TIA).

METHODS

We included a population-based cohort of 771 stroke and TIA patients randomly assigned (1:1) to secondary preventive follow-up within primary health care (control) or nurse-led, telephone-based follow-up (intervention) between January 1, 2010, and December 31, 2013, as part of the NAILED (nurse-based age-independent intervention to limit evolution of disease) stroke risk factor trial. We compared BP and LDL-C levels 12 months after hospital discharge in relation to education level (low, ≤10 years; high, >10 years) separately for the intervention and control groups.

RESULTS

Among controls, systolic BP (SBP) decreased only among the highly educated (-2.5 mm Hg, 95% confidence interval (CI) -0.2 to -4.8), whereas LDL-C increased in the low-education group (0.2 mmol/L, 95% CI 0.1 to 0.3). At 12 months, controls with low education not more than 70 years of age had higher SBP than controls of the same age with high education (5.8 mm Hg, 95% CI 1.0 to 10.6). In contrast, SBP in the intervention group decreased similarly regardless of education level, LDL-C decreased among those with low education (-0.3 mmol/L, 95% CI -0.2 to -0.4) and, in the subgroup not more than 70 years old, low-educated participants had lower LDL-C at 12 months than those with high education (0.3 mmol/L, 95% CI 0.1 to 0.5).

CONCLUSIONS

Nurse-led, telephone-based secondary preventive follow-up led to comparable improvements in BP across education groups, while routine follow-up disfavored those with low education.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN23868518 , June 19, 2012 - Retrospectively registered.

Underuse of Oral Anticoagulants in Patients With Ischemic Stroke and Atrial Fibrillation in China

Anticoagulant therapy is an effective stroke prevention measurement for subjects with atrial fibrillation (AF) who are at high risk of ischemic stroke. However, it is reported that oral anticoagulants (OACs) are generally underused in clinical practice. A better awareness of current usage of anticoagulant therapy would enable prevention of stroke secondary to AF. Therefore, we determined the nationwide prevalence of AF and the frequency of OACs use among patients with ischemic stroke in China. Based on the China National Stroke Screening Survey, a representative nationwide sample of 1,252,703 adults over 40 years old during 2013 and 2014 was involved. Information on demographic data, diagnosis of stroke, behavioral risk factors, family history of stroke, related diseases, and medications was collected. The community-based survey data showed that 5,588 patients (12.0%) with ischemic stroke had previous, or newly diagnosed, AF. Therefore, more than 2.15 million ischemic stroke patients had AF in China. Among ischemic stroke patients with AF, the strongest risk factor was coronary heart disease (odds ratio = 2.53), whereas dyslipidemia accounted for the largest contribution (population-attributable risk proportion = 17.33%). Of ischemic stroke patients with AF, only 2.2% had taken OACs; of them, 98.2% had taken warfarin. In conclusion, a large number of ischemic stroke patients with AF are significantly undertreated with OACs in China. This highlights the need for improvement of prevention of ischemic stroke secondary to AF.

Socioeconomic disparities in first stroke incidence, quality of care, and survival: a nationwide registry-based cohort study of 44 million adults in England

BACKGROUND

We aimed to estimate socioeconomic disparities in the incidence of hospitalisation for first-ever stroke, quality of care, and post-stroke survival for the adult population of England.

METHODS

In this cohort study, we obtained data collected by a nationwide register on patients aged 18 years or older hospitalised for first-ever acute ischaemic stroke or primary intracerebral haemorrhage in England from July 1, 2013, to March 31, 2016. We classified socioeconomic status at the level of Lower Super Output Areas using the Index of Multiple Deprivation, a neighbourhood measure of deprivation. Multivariable models were fitted to estimate the incidence of hospitalisation for first stroke (negative binomial), quality of care using 12 quality metrics (multilevel logistic), and all-cause 1 year case fatality (Cox proportional hazards).

FINDINGS

Of the 43·8 million adults in England, 145 324 were admitted to hospital with their first-ever stroke: 126 640 (87%) with ischaemic stroke, 17 233 (12%) with intracerebral haemorrhage, and 1451 (1%) with undetermined stroke type. We observed a socioeconomic gradient in the incidence of hospitalisation for ischaemic stroke (adjusted incidence rate ratio 2·0, 95% CI 1·7-2·3 for the most vs least deprived deciles) and intracerebral haemorrhage (1·6, 1·3-1·9). Patients from the lowest socioeconomic groups had first stroke a median of 7 years earlier than those from the highest (p<0·0001), and had a higher prevalence of pre-stroke disability and diabetes. Patients from lower socioeconomic groups were less likely to receive five of 12 care processes but were more likely to receive early supported discharge (adjusted odds ratio 1·14, 95% CI 1·07-1·22). Low socioeconomic status was associated with a 26% higher adjusted risk of 1-year mortality (adjusted hazard ratio 1·26, 95% CI 1·20-1·33, for highest vs lowest deprivation decile), but this gradient was largely attenuated after adjustment for the presence of pre-stroke diabetes, hypertension, and atrial fibrillation (1·11, 1·05-1·17).

INTERPRETATION

Wide socioeconomic disparities exist in the burden of ischaemic stroke and intracerebral haemorrhage in England, most notably in stroke hospitalisation risk and case fatality and, to a lesser extent, in the quality of health care. Reducing these disparities requires interventions to improve the quality of acute stroke care and address disparities in cardiovascular risk factors present before stroke.

FUNDING

NHS England and the Welsh Government.

Prevalence of Non-valvular Atrial Fibrillation Based on Geographical Distribution and Socioeconomic Status in the Entire Korean Population

BACKGROUND AND OBJECTIVES

Prevalence of atrial fibrillation (AF) varies based on geographical location and socioeconomic status. We aimed to evaluate the prevalence of AF and utilization of antithrombotic therapy based on geographical regions and income levels in the entire Korean population.

METHODS

We performed a cross-sectional analysis of Korean adults (aged ≥20 years) using the 2015 National Health Insurance Service database (n=41,505,679). The study population was stratified into 17 geographical regions and 21 income levels.

RESULTS

We identified 276,842 patients diagnosed with AF. Overall prevalence of AF in suburban/rural regions was significantly higher than that observed in urban regions (0.72% vs. 0.61%, respectively, p<0.001). Elderly patients (age ≥75 years) showed a higher prevalence of AF and comorbidities related to AF development showed a higher prevalence among the population residing in suburban/rural regions. Among AF patients with a CHA₂DS₂-VASc score ≥2, oral anticoagulation (OAC) therapy utilization was lower in the suburban/rural regions than that observed in the urban regions (48.2% vs. 51.8%, respectively, p<0.001). The relationship between income levels and AF prevalence showed a J-shaped curve. The OAC prescription rate showed a positive correlation with income levels. Non-vitamin K antagonist oral anticoagulants tended to be more commonly prescribed among the higher income groups.

CONCLUSIONS

Geographical location of residence and income levels were closely associated with the prevalence of AF and antithrombotic therapy utilization. This information may provide further insights for more effective surveillance of AF and stroke prevention for improved clinical outcomes.

Stroke survivors' long-term QALY-weights in relation to their spouses' QALY-weights and informal support: a cross-sectional study

Background

Healthcare interventions that have positive effects on the stroke survivors’ health-related quality of life (HRQoL) and quality-adjusted life-years (QALYs) might also have positive effects for their spouses in terms of improved HRQoL and/or reduced spousal informal support. However, knowledge about stroke survivors’ HRQoL and QALY and the consequences for their spouses’ HRQoL and QALY is limited. Therefore, the aim of this study was to describe the HRQoL and QALY-weights in dyads of stroke survivors in comparison with dyads of healthy controls, and to study the relationship between the stroke survivors’ QALY-weights and consequences for spouses in terms of QALY-weight and annual cost of informal support, using a long-term perspective.

Methods

Data on stroke survivors, controls, and spouses were collected from the seven-year follow-up of the Sahlgrenska Academy Study on Ischemic Stroke (SAHLSIS). HRQoL was assessed by the SF-36, and the preference-based health state values were assessed with the SF-6D. The magnitude of the support was assessed with a study specific time-diary. An ordinary least squares (OLS) regression was used to estimate the association between stroke survivors’ and spouses’ QALY-weights. A two-part econometric model was used to estimate the association between stroke survivors’ QALY-weights and the time spent and cost of spouses’ informal support.

Results

Cohabitant dyads of 248 stroke survivors’ aged <70 at stroke onset and 245 controls were included in the study. Stroke survivors had lower HRQoL in the SF-36 domains physical functioning, physical role, general health, vitality (P < 0.001), and social functioning (P = 0.005) in comparison with their cohabitant spouses. There was no significant difference in HRQoL for the dyads of controls. The results from the regression analyses showed that lower QALY-weights of the stroke survivors were associated with lower QALY-weights of their spouses and increased annual cost of spousal informal support.

Conclusion

Our results show that the QALY-weights for stroke survivors had consequences for their spouses in terms of annual cost of spousal informal support and QALY-weights. Hence, economic evaluation of interventions that improve the HRQoL of the stroke survivors but ignore the consequences for their spouses may underestimate the value of the intervention.

Stroke in women - from evidence to inequalities

Stroke is the second largest cause of disability-adjusted life-years lost worldwide. The prevalence of stroke in women is predicted to rise rapidly, owing to the increasing average age of the global female population. Vascular risk factors differ between women and men in terms of prevalence, and evidence increasingly supports the clinical importance of sex differences in stroke. The influence of some risk factors for stroke - including diabetes mellitus and atrial fibrillation - are stronger in women, and hypertensive disorders of pregnancy also affect the risk of stroke decades after pregnancy. However, in an era of evidence-based medicine, women are notably under-represented in clinical trials - despite governmental actions highlighting the need to include both men and women in clinical trials - resulting in a reduced generalizability of study results to women. The aim of this Review is to highlight new insights into specificities of stroke in women, to plan future research priorities, and to influence public health policies to decrease the worldwide burden of stroke in women.

Socioeconomic Status and the Risk of Stroke Recurrence

Background and Purpose—

This nationwide observational study aimed to investigate how socioeconomic status is associated with risk of stroke recurrence and how possible associations change over time.

Methods—

This study included 168 295 patients, previously independent in activities of daily living, with a first-ever stroke in the Swedish Stroke Register (Riksstroke) 2001 to 2012. Riksstroke was linked with Statistics Sweden as to add individual information on education and income. Subdistribution hazard regression was used to analyze time from 28 days after first stroke to stroke recurrence, accounting for the competing risk of other causes of death.

Results—

Median time of follow-up was 3.0 years. During follow-up, 23 560 patients had a first recurrent stroke, and 53 867 died from other causes. The estimated cumulative incidence of stroke recurrence was 5.3% at 1 year, and 14.3% at 5 years. Corresponding incidence for other deaths were 10.3% and 30.2%. Higher education and income were associated with a reduced risk of stroke recurrence. After adjusting for confounding variables, university versus primary school education returned a hazard ratio of 0.902; 95% confidence interval, 0.864 to 0.942, and the highest versus the lowest income tertile a hazard ratio of 0.955; 95% confidence interval, 0.922 to 0.989. The risk of stroke recurrence decreased during the study period, but the inverse effect of socioeconomic status on risk of recurrence did not change significantly.

Conclusions—

Despite a declining risk of stroke recurrence over time, the differences in recurrence risk between different socioeconomic groups remained at a similar level in Sweden during 2001 to 2012.

Patients with atrial fibrillation and outcomes of cerebral infarction in those with treatment of warfarin versus no warfarin with references to CHA2DS2-VASc score, age and sex - A Swedish nationwide observational study with 48 433 patients

AIMS

There is controversy in the guidelines as to whether patients with atrial fibrillation and a low risk of stroke should be treated with anticoagulation, especially those with a CHA2DS2-VASc score of 1 point.

METHODS

In a retrospective, nationwide cohort study, we used the Swedish National Patient Registry, the National Prescribed Drugs Registry, the Swedish Registry of Education and the Population and Housing Census Registry. 48 433 patients were identified between 1 January 2006 and 31 December 2008 with incident atrial fibrillation who were divided in age categories, sex and a CHA2DS2-VASc score of 0, 1, 2 and ≥3 and they were included in a time-varying analysis of warfarin treatment versus no treatment. The primary end-point was cerebral infarction and stroke, and patients were followed until 31 December 2009.

RESULTS

Patients with 1 point from the CHA2DS2-VASc score showed the following adjusted hazard ratios (HR) with a 95% confidence interval: men 65-74 years 0.46 (0.25-0.83), men <65 years 1.11 (0.56-2.23) and women <65 years 2.13 (0.94-4.82), where HR <1 indicates protection with warfarin. In patients <65 years and 2 points, HR in men was 0.35 (0.18-0.69) and in women 1.84 (0.86-3.94) while, in women with at least 3 points, HR was 0.31 (0.16-0.59). In patients 65-74 years and 2 points, HR in men was 0.37 (0.23-0.59) and in women 0.39 (0.21-0.73). Categories including age ≥65 years or ≥3 points showed a statistically significant protection from warfarin.

CONCLUSIONS

Our results support that treatment with anticoagulation may be considered in all patients with an incident atrial fibrillation diagnosis and an age of 65 years and older, i.e. also when the CHA2DS2-VASc score is 1.

Processes and Recommendations for Creating mHealth Apps for Low-Income Populations

BACKGROUND

Mobile health (mHealth) apps have shown to improve health indicators, but concerns remain about the inclusion of populations from low- and medium-income countries (LMIC) in these new technologies. Atrial fibrillation (AF) is a chronic condition with a challenging management. Previous studies have shown socioeconomic differences in the prescription of anticoagulant treatment and shared decision strategies are encouraged to achieve better outcomes. mHealth can aid both doctors and patients in this matter.

OBJECTIVE

We describe the development of an mHealth app (aFib) idealized to aid shared decision between doctor and patient about anticoagulation prophylaxis in AF in a low-income and low-literacy population in Brazil. On the basis of our research, we suggest the processes to be followed when developing mHealth apps in this context.

METHODS

A multidisciplinary team collected information about the target population and its needs and detected the best opportunity to insert the app in their current health care. Literature about the subject was reviewed and important data were selected to be delivered through good navigability, easy terminology, and friendly design. The app was evaluated in a multimethod setting.

RESULTS

The steps suggested to develop an mHealth app target to LMIC are: (1) characterize the problem and the target user, (2) review the literature, (3) translate information to knowledge, (4) protect information, and (5) evaluate usability and efficacy.

CONCLUSIONS

We expect that these recommendations can guide the development of new mHealth apps in LMIC, on a scientific basis.

Associations between Ischemic Stroke Follow-Up, Socioeconomic Status, and Adherence to Secondary Preventive Drugs in Southern Sweden: Observations from the Swedish Stroke Register (Riksstroke)

Background: Currently, the knowledge that one has on adequate stroke follow-up practices is limited. We report associations between 90-day stroke follow-up, socio-economy and adherence to secondary prevention in southern Sweden. Methods: Data on 5,602 patients with ischemic stroke January 1, 2008-December 31, 2010, were obtained from Riksstroke and linked to official registers for information on education, birth country, doctor's follow-ups, and secondary prevention. Primary adherence at 4 months and persistence at 14 months post-stroke were calculated for warfarin, statins, antihypertensive, and antiplatelet drugs. Results: The 90-day follow-up rate was 75%. Patients not receiving a 90-day follow-up had lower age-adjusted OR of persistent drug use at 14 months for antihypertensive agents (OR = 0.74, 95% CI 0.60-0.91) and for antiplatelet drugs (OR = 0.72, 95% CI 0.60-0.87). Drug adherence rates 14 months post-stroke were 85% for antiplatelet drugs, 69% for warfarin, 88% for antihypertensive agents, and 76% for statins. One in three patients discontinued using one or more drug class within 14 months, and nonadherence was associated with activities of daily living dependency at 3 months (age-adjusted OR 0.63, 95% CI 0.57-0.69), but not with age, gender, or educational status. Conclusions: The use of secondary preventive drugs decreases over the first year after stroke and remains suboptimal. Specific reasons for nonadherence warrant further study.

Appropriate assessment of ethnic differences in adolescent use of psychotropic medication: multilevel analysis of discriminatory accuracy

OBJECTIVE

In the present study, we used a multilevel approach to investigate the role of maternal country of birth (MCOB) in predicting adolescent use of psychotropic medication in Sweden.

DESIGN

Using the Swedish Medical Birth Register we identified all 428,314 adolescents born between 1987 and 1990 and who were residing in Sweden in the year they turned 18. We applied multilevel logistic regression analysis with adolescents (level 1) nested within MCOBs (level 2). Measures of association (odds ratio) and measures of variance (intra-class correlation (ICC)) were calculated, as well as the discriminatory accuracy by calculating the area under the Receiver Operator Characteristic (AU-ROC) curve.

RESULTS

In comparison with adolescents with Swedish-born mothers, adolescents with mothers born in upper-middle, lower-middle and low-income countries were less likely to use psychotropic medication. However, the variance between MCOBs was small (ICC = 2.5 in the final model) relative to the variation within MCOBs. This was confirmed by an AU-ROC value of 0.598.

CONCLUSIONS

Even though we found associations between MCOB and adolescent use of psychotropic medication, the small ICC and AU-ROC indicate that MCOB appears to be an inaccurate context for discriminating adolescent use of psychotropic medication in Sweden.

Safely Addressing Patients with Atrial Fibrillation to Early Anticoagulation after Acute Stroke

BACKGROUND

It has been widely reported that anticoagulants (ACs) are underused for primary and secondary prevention of ischemic stroke in patients with atrial fibrillation (AFib). Furthermore, precise evidence-based guidelines about the best timing for AC initiation after acute stroke are currently lacking.

METHODS AND RESULTS

In this retrospective, observational study, we analyzed prescription trends in AFib patients with acute ischemic stroke who were hospitalized in four neurologic stroke units of our region (Lombardia, Italy). In-hospital antithrombotic prescription was performed in highly heterogeneous patterns. A prestroke treatment with AC was the leading factor enhancing AC prescription during hospitalization. The other factors promoting AC were male gender, younger age, lower prestroke disability and stroke severity, and smaller stroke volumes. AFib subtype influenced AC prescription only in AC-naïve patients. Interestingly, Congestive heart failure, Hypertension, Age higher than 75 years, Diabetes, previous Stroke or TIA or thromboembolism, Vascular disease, Age 64-75 years, female Sex (CHA₂DS₂-VASc) and Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INRs, Elderly, Drugs and alcohol (HAS-BLED) scores were not associated with AC prescription. However, patients who were treated with AC, including early treatment (<48 hours), showed a low rate of bleeding.

CONCLUSIONS

Our findings potentially suggest that, although apparently neglecting the common risk stratification tools, our neurologists were able to select the more suitable candidates for prompt AC treatment. Further studies are needed to develop new scoring systems to aid ischemic and hemorrhagic risk estimation in the secondary prevention of stroke.

Clinical Characteristics, Oral Anticoagulation Patterns, and Outcomes of Medicaid Patients With Atrial Fibrillation: Insights From the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF I) Registry

Background

Whereas insurance status has been previously associated with care patterns, little is currently known about the association between Medicaid insurance and the clinical characteristics, treatment, or outcomes of patients with atrial fibrillation (AF).

Methods and Results

We used data from adults with AF enrolled in the Outcomes Registry for Better Informed Treatment of AF (ORBIT‐AF), a national outpatient registry conducted at 176 community, multispecialty sites. The primary outcome of interest was the proportion of patients prescribed any oral anticoagulation (OAC; warfarin or novel oral anticoagulants [NOAC]). Secondary outcomes of interest included the proportion of patients prescribed NOACs (dabigatran or rivaroxaban); time in therapeutic range (TTR) for warfarin users, all‐cause mortality, stroke/systemic embolism, and major bleed. Of 10 133 patients, N=470 (4.6%) had Medicaid insurance. Medicaid patients were similarly likely to receive OAC at baseline (72.8% vs 76.3%; unadjusted P=0.079), but less likely to receive NOAC at baseline or follow‐up (12.1% vs 16.3%; unadjusted P=0.019). After risk adjustment, Medicaid status was associated with lower use of OAC at baseline among patients with high stroke risk (odds ratio [OR]=0.68; 95% CI=0.49, 0.94), but was not associated with OAC use overall (OR=0.82; 95% CI=0.61, 1.09). Among warfarin users, median TTR was lower among Medicaid patients (60% vs 68%; P<0.0001; adjusted TTR difference, −2.9; 95% CI=−5.7, −0.2; P=0.04). Use of an NOAC over 2 years of follow‐up was not statistically different by insurance. Compared with non‐Medicaid patients, Medicaid patients had higher unadjusted rates of mortality, stroke/systemic embolism, and major bleeding; however, these differences were attenuated following adjustment for clinical characteristics.

Conclusions

In a contemporary AF cohort, use of OAC overall and use of NOACs were not significantly lower among Medicaid patients relative to others. However, among warfarin users, Medicaid patients spent less time in therapeutic range compared with those with other forms of insurance.