Poor outcomes associated with antithrombotic undertreatment in patients with atrial fibrillation attending Gondar University Hospital: a retrospective cohort study

The Prevalence and Determinants of Inappropriate Oral Anticoagulant Use in Patients with Atrial Fibrillation, in Resource-Limited Setting

Introduction

Anticoagulation treatment is routinely underused in patients with atrial fibrillation (AF), particularly in settings with limited resources. The current study is aimed at evaluating the appropriateness of oral anticoagulation treatment among AF patients at the Yekatit 12 Hospital Medical College (Y12HMC), Addis Ababa, Ethiopia.

Methods

Institutional-based retrospective cross-sectional study conducted in Y12HMC from November 2019 to March 2020. During the study period, 256 patients' medical records were found; 231 of them met the eligibility criteria and were included in the study. The data were analyzed using SPSS version 25, descriptive statistics were used to summarize the data, and binary logistic regression was performed to identify predictors of inappropriate anticoagulation management.

Results

The majority of study participants were males (55.8%), and over half of them (57.6%) had a nonvalvular type of AF. The majority of patients (61.9%) were receiving anticoagulant treatment, and of them, warfarin was prescribed to most of the study subjects (71.3%). Nearly half (47.6%) of the study participants had inappropriate anticoagulation treatment; among these, the majority of them (69.1%) were from a valvular type of AF. Patients with a valvular type of AF and having the diagnosis of congestive heart disease as comorbidity showed a statistically significant association towards inappropriate anticoagulation management.

Conclusion

According to the study, a significant portion of AF patients received inappropriate anticoagulant treatment, which may play a significant role for the increased risk of stroke in these groups of patients. All of the inappropriate cases were due to failure to start anticoagulant treatment.

Screening over 100 000 patients in 39 general practices in the Netherlands for anticoagulation underprescription in atrial fibrillation: a descriptive, cross-sectional study

OBJECTIVES

To investigate the underprescription of oral anticoagulation (OAC) in individual atrial fibrillation (AF) patients in primary care.

SETTING

Screening of patient records in 39 participating general practitioners (GPs) across the Netherlands.

PARTICIPANTS

We screened 101 207 patient records identifying 2375 non-valvular AF patients.

METHODS

Using electronic patient files, we were able to screen the entire GP population for AF, CHA2DS2-VASc stroke risk scores, and the use of guidelines recommended OAC prescription. In case of a deviation from guidelines recommended OAC prescription, we checked the electronic patient file for any documented reason. Additionally, 6 weeks following the screening, we asked all GPs to provide information on any actions taken for the underprescribed patients.

RESULTS

We found a mean CHA2DS2-VASc score of 3.2. OAC prescription consisted of direct OAC in 1342/1984 (68%) and vitamin K-antagonists in the remainder of patients. OAC underprescription was present in 93/944 (9.9%) females and 101/1374 (9.7%) in males, respectively. In 111/146 (76.0%) of the underprescribed AF patients, no reason to withhold OAC was reported. Reported reasons to withhold OAC were patient refusal (n=10), cardiologist advice (n=7) and high risk of bleeding (n=7). Data regarding actions following the identification of OAC underprescription were available for 92/194 (47%) of the OAC underprescribed cases. After consultation OAC was initiated in 9/92 (10%) only.

CONCLUSIONS

In this large Dutch study among GPs, we observed 9.8% underprescription of OAC in AF patients. In 76% of the AF patients lacking a prescription for OAC, no documentation for deviating from the guidelines was found. Only in a minority of cases detection of OAC underprescription lead to OAC initiation.

Undertreatment of Anticoagulant Therapy in Hospitalized Acute Ischemic Stroke Patients With Atrial Fibrillation

Background

This study aimed to investigate the prevalence and factors associated with the initiation of oral anticoagulation among patients with acute ischemic stroke (AIS) and concurrent atrial fibrillation (AF) at discharge in China.

Methods

We continuously included hospitalized patients with AIS with an AF diagnosis registered in the computer-based Online Database of Acute Stroke Patients for Stroke Management Quality Evaluation (CASE II) from January 2016 to December 2020 and divided them into a and non-anticoagulant groups according to the medications at discharge. Binary logistic regression was used to determine the factors associated with the prescription of anticoagulants in patients with AF.

Results

A total of 16,162 patients were enrolled. The mean age was 77 ± 9 years, 8,596 (53.2%) were males, and the median baseline National Institute of Health Stroke Scale score was 5 (2–12). Of the 14,838 patients without contraindications of antithrombotic therapy, 6,335 (42.7%) patients were initiated with anticoagulation treatment at discharge. Prior history of hemorrhagic stroke (OR 0.647, p < 0.001) and gastrointestinal bleeding (OR 0.607, p = 0.003) were associated with a lower rate of anticoagulation at discharge. Patients with any intracranial hemorrhage (OR 0.268, p < 0.001), gastrointestinal bleeding (OR 0.353, p < 0.001), or pneumonia during hospitalization (OR 0.601, p < 0.001) were less likely to receive anticoagulants at discharge. Among 7,807 patients with previously diagnosed AF and high risk of stroke (CHA₂DS₂-VASc ≥2), only 1,585 (20.3%) had been receiving anticoagulation treatment prior to the onset of stroke. However, the mean international normalized ratio (INR) was 1.5 on the first test during hospitalization in patients receiving warfarin. Patients complicated with a previous history of ischemic stroke/transient ischemic attack (TIA; OR 2.303, p < 0.001) and peripheral artery disease (OR 1.456, p = 0.003) were more common to start anticoagulants.

Conclusions

Less than half of patients with AIS and concurrent AF initiated guideline-recommended oral anticoagulation at discharge, while only 20% of patients with previously diagnosed AF with a high risk of stroke had been using anticoagulants prior to the onset of stroke, which highlights a large care gap in hospitalized stroke patients and the importance of AF management.

Non-adherence to Thromboprophylaxis Guidelines in Atrial Fibrillation: A Narrative Review of the Extent of and Factors in Guideline Non-adherence

Atrial fibrillation is the most common arrhythmia. It increases the risk of thromboembolism by up to fivefold. Guidelines provide evidence-based recommendations to effectively mitigate thromboembolic events using oral anticoagulants while minimizing the risk of bleeding. This review focuses on non-adherence to contemporary guidelines and the factors associated with guideline non-adherence. The extent of guideline non-adherence differs according to geographic region, healthcare setting, and risk stratification tools used. Guideline adherence has gradually improved over recent years, but a significant proportion of patients are still not receiving guideline-recommended therapy. Physician-related and patient-related factors (such as patient refusals, bleeding risk, older age, and recurrent falls) also contribute to guideline non-adherence, especially to undertreatment. Quality improvement initiatives that focus on undertreatment, especially in the primary healthcare setting, may help to improve guideline adherence.

Adherence to anticoagulant guideline for atrial fibrillation: A large care gap among stroke patients in a rural population

OBJECTIVE

This study aimed to investigate the prevalence and factors associated with oral anticoagulant undertreatment of atrial fibrillation (AF) among a cohort of rural patients with stroke outcomes and examine how undertreatment may influence a patient's one-year survival after stroke.

METHODS

This retrospective cohort study examined ischemic stroke patients with pre-stroke AF diagnosis from September 2003 to May 2019 and divided them into proper treatment and undertreatment group. Analysis included chi-square test, variance analysis, Kruskal-Wallis test, logistic regression, Kaplan-Meier estimator, and Cox proportional-hazards model.

RESULTS

Out of 1062 ischemic stroke patients with a pre-stroke AF diagnosis, 1015 patients had a CHA₂DS₂-VASc score ≥2, and 532 (52.4%) of those were undertreated. Median time from AF diagnosis to index stroke was significantly lower among undertreated patients (1.9 years vs. 3.6 years, p < 0.001). Other thromboembolism, excluding stroke, TIA, and myocardial infarction (OR 0.41, p < 0.001), the number of encounters per year (OR 0.90, p < 0.001), and the median time between AF diagnosis and stroke event (OR 0.86, p < 0.001) were negatively associated with undertreatment. Kaplan-Meier estimator showed no statistical difference in the one-year survival probability between groups (log-rank test, p = 0.29), while the Cox-Hazard model showed that age (HR 1.05, p < 0.001) and history of congestive heart failure (HR 1.88, p < 0.001) increased the risk of mortality.

CONCLUSIONS

More than half of our rural stroke patients with a pre-index AF diagnosis were not on guideline-recommended treatment. The study highlights a large care gap and an opportunity to improve AF management.

Adherence to Antithrombotic Treatment and Ischemic Stroke Recurrence in Egypt and Germany: A Comparative Analysis

BACKGROUND

The burden of stroke weighs heavily in developing countries where recurrence rates clearly exceed that of developed countries. The impact of nonadherence to antithrombotic treatment within this context has been poorly investigated.

OBJECTIVE

The objective of this study was to evaluate patients with recurrent ischemic stroke in Egypt and Germany with focus on stroke subtype distribution and adherence to antithrombotic therapy.

METHODS

We conducted a comparative cross-sectional retrospective cohort study enrolling consecutive patients hospitalized for recurrent ischemic stroke in 2017 in 2 academic centers. Data were collected on demographics, risk factors, stroke subtypes, and medication adherence. Nonadherence to antithrombotic agents was analyzed at the time point of index stroke (recurrent stroke). Predictors of nonadherence were analyzed using logistic regression.

RESULTS

A total of 373 Egyptian and 468 German patients with ischemic stroke were included. The proportion of recurrent ischemic stroke among all patients was higher in the Egyptian cohort compared to the German cohort (33 vs. 10%, p < 0.05). Small-vessel occlusion stroke was the most frequent subtype in Egyptians, with a significantly greater proportion than in Germans (45 vs. 26%, p < 0.05). Nonadherence to antiplatelets at the time point of the recurrent stroke was higher in Egyptians than in Germans (82 vs. 19%, p < 0.001). Low educational attainment among Egyptians (OR 0.14, 95% CI [0.00-0.19], p < 0.01) and high comorbidity scores among Germans (OR 2.45, 95% CI [1.06-5.66], p < 0.05) were found to be predictors of nonadherence to antithrombotic treatment.

CONCLUSIONS

The large stroke recurrence burden in Egypt may be partly explained by differing adherence to secondary preventative antithrombotic pharmacotherapy. Predictors of medication nonadherence have to be addressed to reduce stroke recurrence disparities.

Prestroke statins use reduces oxidized low density lipoprotein levels and improves clinical outcomes in patients with atrial fibrillation related acute ischemic stroke

Background

Atrial fibrillation (AF) is a common cause of cerebral infarction, which could lead to endothelial dysfunction, increased reactive oxygen species (ROS) and oxidized low density lipoprotein (Ox-LDL).AF is associated with higher mortality and more severe neurologic disability. Statins may exert neuroprotective effects that are independent of LDL-C lowering. The purpose of our study was to investigate whether prestroke statins use could reduce plasma Ox-LDL levels and improve clinical outcomes in patients with AF-related acute ischemic stroke (AIS).

Methods

This was a multicenter prospective study that involved four medical centers, 242 AIS patients with AF were identified, who underwent a comprehensive clinical investigation and a 72 h-Holter electrocardiogram monitoring. All patients were divided into two groups: prestroke statins use and no prestroke statins use groups, who were followed up for 3 months. Plasma Ox-LDL levels were measured using enzyme-linked immunosorbent assay (ELISA) on admission and at 3 months. The outcome was death, major disability (modified Rankin Scale score ≥ 3), and composite outcome (death/major disability) at 3 months after AIS.

Results

One hundred thirty-six patients were in no prestroke statins use group, and 106 in prestroke statins use group. Plasma Ox-LDL levels were significantly lower in prestroke statins use than in no prestroke statins use on admission and at 3 months (P < 0.001). Plasma Ox-LDL levels on admission were associated with 3-month mortality [adjusted odds ratio (OR), 1.05; 95% confidence interval (CI), 0.99–1.12; P = 0.047]. In fully adjusted models, prestroke statins use was associated with reduced 3-month mortality [adjusted OR, 0.38; 95% CI, 0.16–0.91; P = 0.031)], major disability (adjusted OR, 0.38; 95% CI, 0.15–0.99; P = 0.047), and composite outcome (adjusted OR, 0.31; 95% CI, 0.17–0.74; P = 0.009).

Conclusions

Prestroke statins use can reduce plasma Ox-LDL levels and improve clinical outcomes in patients with AF-related AIS.

In-Hospital Mortality among Ischemic Stroke Patients in Gondar University Hospital: A Retrospective Cohort Study

Introduction

Ischemic stroke is the third leading cause of mortality in low-income countries and the sixth in Ethiopia. The aim of this study was to determine the rate and predictors of in-hospital mortality due to ischemic stroke in Gondar University Hospital.

Methods

The study was conducted from April 1, 2017, to May 15, 2017, at Gondar University Hospital. A census using retrospective cohort study design was conducted on medical records of adult patients with the diagnosis of ischemic stroke attending the medical inpatient ward of Gondar University Hospital between November 2012 and September 2016. Cox hazard regression was used to determine the predictors of in-hospital mortality. A two-sided statistical test at 5% level of significance was used.

Results

The mean (±SD) duration of hospital stay was 11.55 (10.040) days. Of the total 208 patients, 26 (12.5%) patients died in the hospital. Cox regression revealed that only a decrease in renal function, particularly elevated serum creatinine (AHR=8.848, 95% CI: 1.616-67.437), was associated with a statistically significant increase of in-hospital mortality. The symptom onset-to-admission time varied greatly among patients and ranged from 1 hour to 168 hours.

Conclusion

The in-hospital mortality associated with ischemic stroke was found to be high. Mainly, elevation in serum creatinine was highly associated with poorer outcomes in terms of in-hospital mortality. Much work should be done on improving the knowledge and awareness of the community regarding ischemic stroke and stroke in general to encourage early medical seeking behavior and reduce mortality and long-term disability.