Temporal Trends in Pharmacological Stroke Prevention in Patients with Acute Ischemic Stroke and Known Atrial Fibrillation.

INTRODUCTION: Oral anticoagulation (OAC) substantially reduces stroke risk in patients with atrial fibrillation (AF) at risk for stroke. Whether non-vitamin K-dependent oral anticoagulants (NOACs) improve OAC use in stroke prevention requires investigation. METHODS: To investigate temporal trends of OAC use in patients with known AF pre-stroke, we retrospectively analyzed records of 6,803 stroke patients admitted in 2003-2004 (n=1,496), 2008-2010 (n=1,638) or 2013-2015 (n=3,669) to the Charité-Universitätsmedizin Berlin, Germany. Adjusted regression models were used to identify factors associated with OAC use. RESULTS: Of 1,209 AF patients (mean age 79 years, 55.9% female) with given indication for OAC according to the CHADS2/CHA2DS2-VASc score, 484 (40.0%) were anticoagulated prior to the index stroke, 458 (37.9%) received antiplatelets and 236 (19.5%) had no antithrombotic medication. Compared to 2003-2004 and 2008-2010, there was a higher rate of pre-admission OAC in 2013-2015 (28.2% vs. 49.6%, p<0.001). After adjustment for possible confounders, factors associated with OAC pre-admission were young age (OR 0.74 per decade [95%CI 0.64-0.85]), previous stroke/TIA (OR 1.29 [95%CI 1.00-1.67]), absence of heart failure (OR 0.63 [95%CI 0.47-0.85]) and admission in 2013-2015 (OR 2.45 [95%CI 1.91-3.15]). Prescription of OAC at hospital discharge increased from 2003-2010 compared to 2013-2015 (45.2% vs. 69.5%, p < 0.001). CONCLUSIONS: Irrespective of temporal trends and despite given indication, more than half of all patients with known AF were not anticoagulated prior to the index stroke. In the NOAC era, there was an increase in OAC intake pre-stroke and a higher rate of OAC prescription at hospital discharge in stroke survivors with known AF.

Impact of chronic inflammatory airway disease on stroke severity and long-term survival after ischemic stroke--a retrospective analysis.

BACKGROUND: Chronic inflammatory airway disease (CIAD) has emerged as independent risk factor for cardiovascular mortality and ischemic stroke but the impact of co-existing CIAD in patients with ischemic stroke is less clear. METHODS: We retrospectively analyzed 1013 patients with acute ischemic stroke who were consecutively admitted to the Department of Neurology, Charité - Universitätsmedizin Berlin, Germany within one year. Mean follow-up was 80 months (IQR 32-85 months). Using multivariable regression models we analyzed the impact of CIAD (defined as chronic obstructive pulmonary disease or asthma bronchiale) on stroke severity and outcome. RESULTS: Co-existing CIAD was evident in 7.1 % (n = 72) of all patients with acute ischemic stroke. Baseline characteristics of stroke patients with CIAD did not differ significantly from ischemic stroke patients without CIAD. Age (OR 1.17 [95 % CI 1.03-1.37] per decade), atrial fibrillation (OR 3.43 [95 % CI 2.47-4.78]) and coronary artery disease (OR 1.51 [95 % CI 1.07-2.14]) but not a history of CIAD (p = 0.30) were associated with severe stroke (NIHSS≥11) on hospital admission. Age (HR 1.70 [95 % CI 1.53-1.87] per decade), peripheral artery disease (HR 1.91 [95 % CI 1.35-2.7]), stroke severity at hospital admission (NIHSS per point HR 1.08 [95 % CI 1.06-1.10]), and history of CIAD (HR 1.43 [95 % CI 1.02-2.00]) were independently associated with mortality during long-term follow-up. However, CIAD was not significantly associated with short-term mortality after stroke. CONCLUSION: Co-existing CIAD showed no significant association with stroke severity at hospital admission and early mortality after ischemic stroke. CIAD was negatively associated with long-term survival after ischemic stroke.

Should transesophageal echocardiography be performed in acute stroke patients with atrial fibrillation?

The diagnostic need for echocardiography in acute stroke patients with documented atrial fibrillation (AF) is controversial because the index stroke per se is an indication for therapeutic anticoagulation according to guidelines. We retrospectively analyzed medical records of 2390 stroke patients consecutively admitted over a 2-year period to three different stroke units at university hospitals in Berlin, Germany. AF was diagnosed in 21.2% (n=506) of 2185 patients with acute ischemic stroke or transient ischemic attack. Overall, 36.6% (n=185) of all AF patients underwent transesophageal echocardiography (TEE) or transthoracic echocardiography within days of hospital admission. According to multivariate analysis, age and in-hospital conventions determined the diagnostic use of TEE in stroke patients with known AF, while the existing cardiovascular risk profile had no impact. Major cardiac sources of embolism were identified by echocardiography in 9.7% (n=18) of all AF patients with acute stroke, including non-AF-related sources of embolism in 3.8% (n=7). However, echocardiographic findings did not result in any therapeutic intervention other than immediate anticoagulation. Furthermore, echocardiographic findings had no impact on the prescription of anticoagulants at hospital discharge or long-term survival. Taken together, our data indicate that diagnostic echocardiography offers only a little additional information and does not impact clinical management and outcome in acute stroke patients with known AF.

Impact of anticoagulation before stroke on stroke severity and long-term survival.

BACKGROUND: Therapeutic anticoagulation by vitamin K antagonists is highly effective in reducing stroke risk in patients with atrial fibrillation. Vitamin K antagonist treatment before stroke reduces stroke severity and short-term mortality. AIMS: This study analyses vitamin K antagonists, used in patients with atrial fibrillation diagnosed before the index stroke. We also focus on the impact of preadmission antithrombotic medication on long-term survival. METHODS: We analyzed 2390 stroke patients consecutively admitted to the Department of Neurology, Charité Berlin, Germany between 2003 and 2004. Mean follow-up was 38 months (range 0-68). Using univariable and multivariable regression models, we identified factors for preadmission anticoagulation in patients with known atrial fibrillation and analyzed the impact of antithrombotic therapy preadmission on functional disability and long-term survival after stroke. RESULTS: Atrial fibrillation was diagnosed in 534 (22·3%) of the 2390 stroke patients. In 348 (65·2%) of all atrial fibrillation patients, atrial fibrillation was already known before the index stroke. Three hundred twenty-five (93·4%) atrial fibrillation patients were amenable to anticoagulation, according to guidelines, 75 (23·1%) received vitamin K antagonists, and 20 (6·2%) had an international normalized ratio of 2-3 at the time of stroke onset. Males and younger patients were more likely to receive anticoagulation preadmission, while previous stroke had no significant impact on vitamin K antagonist prescription. Age (odds ratio 1·02 (95% confidence interval 1·00-1·04) per year), history of coronary artery disease (odds ratio 1·51 (95% confidence interval 1·01-2·26)), and therapeutic anticoagulation (odds ratio 0·28 (0·09-0·84)) were independent predictors of stroke severity. Age (hazard rates 3·11 (95% confidence interval 1·47-6·59), 4·65 (95% confidence interval 2·27-9·57), and 11·1 (95% confidence interval 4·90-25·1) for age categories 65-74, 75-84, and ≥85 years), preadmission antiplatelet therapy (hazard rate 1·85 (95% confidence interval 1·21-2·82)), and stroke severity on admission (hazard rate 1·60 (95% confidence interval 1·03-2·46) and hazard rate 3·23 (95% confidence interval 1·88-5·55) for National Institutes of Health Stroke Scale categories 6-15 and >15 points) were associated with risk of death during follow-up. CONCLUSIONS: In patients in which atrial fibrillation was diagnosed prior to the index stroke, about 23% received anticoagulation according to guideline recommendations. Therapeutic anticoagulation at stroke onset significantly decreased the risk of moderate to severe stroke on admission but showed no significant association with long-term survival.