Association of preceding antithrombotic treatment with acute ischemic stroke severity and in-hospital outcomes among patients with atrial fibrillation

Ying Xian, Emily C. O'Brien, Li Liang, Haolin Xu, Lee H. Schwamm, Gregg C. Fonarow, Deepak L. Bhatt, Eric E. Smith, Dai Wai M. Olson, Lesley Maisch, Deidre Hannah, Brianna Lindholm, Barbara L. Lytle, Michael J. Pencina, Adrian F. Hernandez, Eric D. Peterson

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Abstract

IMPORTANCE Antithrombotic therapies are known to prevent stroke for patients with atrial fibrillation (AF) but are often underused in community practice. OBJECTIVES To examine the prevalence of patients with acute ischemic stroke with known history of AF who were not receiving guideline-recommended antithrombotic treatment before stroke and to determine the association of preceding antithrombotic therapy with stroke severity and in-hospital outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective observational study of 94 474 patients with acute ischemic stroke and known history of AF admitted from October 2012 through March 2015 to 1622 hospitals participating in the Get With the Guidelines-Stroke program. EXPOSURES Antithrombotic therapy before stroke. MAIN OUTCOMES AND MEASURES Stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS; range of 0-42, with a higher score indicating greater stroke severity and a score≥16 indicating moderate or severe stroke), and in-hospital mortality. RESULTS Of 94 474 patients (mean [SD] age, 79.9 [11.0] years; 57.0%women), 7176 (7.6%) were receiving therapeuticwarfarin (international normalized ratio [INR]≥2) and 8290(8.8%) were receiving non-vitamin K antagonist oral anticoagulants (NOACs) preceding the stroke. A total of 79 008patients (83.6%)were not receiving therapeutic anticoagulation; 12 751 (13.5%) had subtherapeuticwarfarin anticoagulation (INR <2) at the time of stroke, 37 674 (39.9%)were receiving antiplatelet therapy only, and 28 583 (30.3%)were not receiving any antithrombotic treatment. Among 91 155 high-risk patients (prestroke CHA2DS2-VASc score≥2), 76071 (83.5%)were not receiving therapeuticwarfarin orNOACs before stroke. The unadjusted rates of moderate or severe strokewere lower among patients receiving therapeuticwarfarin (15.8% [95%CI, 14.8%-16.7%]) andNOACs (17.5%[95%CI, 16.6%-18.4%]) than among those receiving no antithrombotic therapy (27.1%[95%CI, 26.6%-27.7%]), antiplatelet therapy only (24.8%[95%CI, 24.3%-25.3%]), or subtherapeuticwarfarin (25.8% [95%CI, 25.0%-26.6%]); unadjusted rates of in-hospital mortality alsowere lower for those receiving therapeuticwarfarin (6.4%[95%CI, 5.8%-7.0%]) and NOACs (6.3%[95%CI, 5.7%- 6.8%]) compared with those receiving no antithrombotic therapy (9.3%[95%CI, 8.9%-9.6%]), antiplatelet therapy only (8.1%[95%CI, 7.8%-8.3%]), or subtherapeuticwarfarin (8.8% [95% CI, 8.3%-9.3%]). After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeuticwarfarin,NOACs, or antiplatelet therapywas associated with lower odds of moderate or severe stroke (adjusted odds ratio [95%CI],0.56 [0.51-0.60], 0.65 [0.61-0.71], and0.88 [0.84-0.92], respectively) and in-hospital mortality (adjusted odds ratio [95%CI],0.75 [0.67-0.85],0.79 [0.72-0.88], and0.83 [0.78-0.88], respectively). CONCLUSIONS AND RELEVANCE Among patients with atrial fibrillation who had experienced an acute ischemic stroke, inadequate therapeutic anticoagulation preceding the stroke was prevalent. Therapeutic anticoagulation was associated with lower odds of moderate or severe stroke and lower odds of in-hospital mortality.

Original languageEnglish (US)
Pages (from-to)1057-1067
Number of pages11
JournalJAMA - Journal of the American Medical Association
Volume317
Issue number10
DOIs
StatePublished - Mar 14 2017

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Atrial Fibrillation
Stroke
Therapeutics
Hospital Mortality
Anticoagulants
International Normalized Ratio
Odds Ratio
Guidelines
National Institutes of Health (U.S.)
Observational Studies

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Association of preceding antithrombotic treatment with acute ischemic stroke severity and in-hospital outcomes among patients with atrial fibrillation. / Xian, Ying; O'Brien, Emily C.; Liang, Li; Xu, Haolin; Schwamm, Lee H.; Fonarow, Gregg C.; Bhatt, Deepak L.; Smith, Eric E.; Olson, Dai Wai M.; Maisch, Lesley; Hannah, Deidre; Lindholm, Brianna; Lytle, Barbara L.; Pencina, Michael J.; Hernandez, Adrian F.; Peterson, Eric D.

In: JAMA - Journal of the American Medical Association, Vol. 317, No. 10, 14.03.2017, p. 1057-1067.

Research output: Contribution to journalArticle

Xian, Y, O'Brien, EC, Liang, L, Xu, H, Schwamm, LH, Fonarow, GC, Bhatt, DL, Smith, EE, Olson, DWM, Maisch, L, Hannah, D, Lindholm, B, Lytle, BL, Pencina, MJ, Hernandez, AF & Peterson, ED 2017, 'Association of preceding antithrombotic treatment with acute ischemic stroke severity and in-hospital outcomes among patients with atrial fibrillation', JAMA - Journal of the American Medical Association, vol. 317, no. 10, pp. 1057-1067. https://doi.org/10.1001/jama.2017.1371
Xian, Ying ; O'Brien, Emily C. ; Liang, Li ; Xu, Haolin ; Schwamm, Lee H. ; Fonarow, Gregg C. ; Bhatt, Deepak L. ; Smith, Eric E. ; Olson, Dai Wai M. ; Maisch, Lesley ; Hannah, Deidre ; Lindholm, Brianna ; Lytle, Barbara L. ; Pencina, Michael J. ; Hernandez, Adrian F. ; Peterson, Eric D. / Association of preceding antithrombotic treatment with acute ischemic stroke severity and in-hospital outcomes among patients with atrial fibrillation. In: JAMA - Journal of the American Medical Association. 2017 ; Vol. 317, No. 10. pp. 1057-1067.
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title = "Association of preceding antithrombotic treatment with acute ischemic stroke severity and in-hospital outcomes among patients with atrial fibrillation",
abstract = "IMPORTANCE Antithrombotic therapies are known to prevent stroke for patients with atrial fibrillation (AF) but are often underused in community practice. OBJECTIVES To examine the prevalence of patients with acute ischemic stroke with known history of AF who were not receiving guideline-recommended antithrombotic treatment before stroke and to determine the association of preceding antithrombotic therapy with stroke severity and in-hospital outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective observational study of 94 474 patients with acute ischemic stroke and known history of AF admitted from October 2012 through March 2015 to 1622 hospitals participating in the Get With the Guidelines-Stroke program. EXPOSURES Antithrombotic therapy before stroke. MAIN OUTCOMES AND MEASURES Stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS; range of 0-42, with a higher score indicating greater stroke severity and a score≥16 indicating moderate or severe stroke), and in-hospital mortality. RESULTS Of 94 474 patients (mean [SD] age, 79.9 [11.0] years; 57.0{\%}women), 7176 (7.6{\%}) were receiving therapeuticwarfarin (international normalized ratio [INR]≥2) and 8290(8.8{\%}) were receiving non-vitamin K antagonist oral anticoagulants (NOACs) preceding the stroke. A total of 79 008patients (83.6{\%})were not receiving therapeutic anticoagulation; 12 751 (13.5{\%}) had subtherapeuticwarfarin anticoagulation (INR <2) at the time of stroke, 37 674 (39.9{\%})were receiving antiplatelet therapy only, and 28 583 (30.3{\%})were not receiving any antithrombotic treatment. Among 91 155 high-risk patients (prestroke CHA2DS2-VASc score≥2), 76071 (83.5{\%})were not receiving therapeuticwarfarin orNOACs before stroke. The unadjusted rates of moderate or severe strokewere lower among patients receiving therapeuticwarfarin (15.8{\%} [95{\%}CI, 14.8{\%}-16.7{\%}]) andNOACs (17.5{\%}[95{\%}CI, 16.6{\%}-18.4{\%}]) than among those receiving no antithrombotic therapy (27.1{\%}[95{\%}CI, 26.6{\%}-27.7{\%}]), antiplatelet therapy only (24.8{\%}[95{\%}CI, 24.3{\%}-25.3{\%}]), or subtherapeuticwarfarin (25.8{\%} [95{\%}CI, 25.0{\%}-26.6{\%}]); unadjusted rates of in-hospital mortality alsowere lower for those receiving therapeuticwarfarin (6.4{\%}[95{\%}CI, 5.8{\%}-7.0{\%}]) and NOACs (6.3{\%}[95{\%}CI, 5.7{\%}- 6.8{\%}]) compared with those receiving no antithrombotic therapy (9.3{\%}[95{\%}CI, 8.9{\%}-9.6{\%}]), antiplatelet therapy only (8.1{\%}[95{\%}CI, 7.8{\%}-8.3{\%}]), or subtherapeuticwarfarin (8.8{\%} [95{\%} CI, 8.3{\%}-9.3{\%}]). After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeuticwarfarin,NOACs, or antiplatelet therapywas associated with lower odds of moderate or severe stroke (adjusted odds ratio [95{\%}CI],0.56 [0.51-0.60], 0.65 [0.61-0.71], and0.88 [0.84-0.92], respectively) and in-hospital mortality (adjusted odds ratio [95{\%}CI],0.75 [0.67-0.85],0.79 [0.72-0.88], and0.83 [0.78-0.88], respectively). CONCLUSIONS AND RELEVANCE Among patients with atrial fibrillation who had experienced an acute ischemic stroke, inadequate therapeutic anticoagulation preceding the stroke was prevalent. Therapeutic anticoagulation was associated with lower odds of moderate or severe stroke and lower odds of in-hospital mortality.",
author = "Ying Xian and O'Brien, {Emily C.} and Li Liang and Haolin Xu and Schwamm, {Lee H.} and Fonarow, {Gregg C.} and Bhatt, {Deepak L.} and Smith, {Eric E.} and Olson, {Dai Wai M.} and Lesley Maisch and Deidre Hannah and Brianna Lindholm and Lytle, {Barbara L.} and Pencina, {Michael J.} and Hernandez, {Adrian F.} and Peterson, {Eric D.}",
year = "2017",
month = "3",
day = "14",
doi = "10.1001/jama.2017.1371",
language = "English (US)",
volume = "317",
pages = "1057--1067",
journal = "JAMA - Journal of the American Medical Association",
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TY - JOUR

T1 - Association of preceding antithrombotic treatment with acute ischemic stroke severity and in-hospital outcomes among patients with atrial fibrillation

AU - Xian, Ying

AU - O'Brien, Emily C.

AU - Liang, Li

AU - Xu, Haolin

AU - Schwamm, Lee H.

AU - Fonarow, Gregg C.

AU - Bhatt, Deepak L.

AU - Smith, Eric E.

AU - Olson, Dai Wai M.

AU - Maisch, Lesley

AU - Hannah, Deidre

AU - Lindholm, Brianna

AU - Lytle, Barbara L.

AU - Pencina, Michael J.

AU - Hernandez, Adrian F.

AU - Peterson, Eric D.

PY - 2017/3/14

Y1 - 2017/3/14

N2 - IMPORTANCE Antithrombotic therapies are known to prevent stroke for patients with atrial fibrillation (AF) but are often underused in community practice. OBJECTIVES To examine the prevalence of patients with acute ischemic stroke with known history of AF who were not receiving guideline-recommended antithrombotic treatment before stroke and to determine the association of preceding antithrombotic therapy with stroke severity and in-hospital outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective observational study of 94 474 patients with acute ischemic stroke and known history of AF admitted from October 2012 through March 2015 to 1622 hospitals participating in the Get With the Guidelines-Stroke program. EXPOSURES Antithrombotic therapy before stroke. MAIN OUTCOMES AND MEASURES Stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS; range of 0-42, with a higher score indicating greater stroke severity and a score≥16 indicating moderate or severe stroke), and in-hospital mortality. RESULTS Of 94 474 patients (mean [SD] age, 79.9 [11.0] years; 57.0%women), 7176 (7.6%) were receiving therapeuticwarfarin (international normalized ratio [INR]≥2) and 8290(8.8%) were receiving non-vitamin K antagonist oral anticoagulants (NOACs) preceding the stroke. A total of 79 008patients (83.6%)were not receiving therapeutic anticoagulation; 12 751 (13.5%) had subtherapeuticwarfarin anticoagulation (INR <2) at the time of stroke, 37 674 (39.9%)were receiving antiplatelet therapy only, and 28 583 (30.3%)were not receiving any antithrombotic treatment. Among 91 155 high-risk patients (prestroke CHA2DS2-VASc score≥2), 76071 (83.5%)were not receiving therapeuticwarfarin orNOACs before stroke. The unadjusted rates of moderate or severe strokewere lower among patients receiving therapeuticwarfarin (15.8% [95%CI, 14.8%-16.7%]) andNOACs (17.5%[95%CI, 16.6%-18.4%]) than among those receiving no antithrombotic therapy (27.1%[95%CI, 26.6%-27.7%]), antiplatelet therapy only (24.8%[95%CI, 24.3%-25.3%]), or subtherapeuticwarfarin (25.8% [95%CI, 25.0%-26.6%]); unadjusted rates of in-hospital mortality alsowere lower for those receiving therapeuticwarfarin (6.4%[95%CI, 5.8%-7.0%]) and NOACs (6.3%[95%CI, 5.7%- 6.8%]) compared with those receiving no antithrombotic therapy (9.3%[95%CI, 8.9%-9.6%]), antiplatelet therapy only (8.1%[95%CI, 7.8%-8.3%]), or subtherapeuticwarfarin (8.8% [95% CI, 8.3%-9.3%]). After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeuticwarfarin,NOACs, or antiplatelet therapywas associated with lower odds of moderate or severe stroke (adjusted odds ratio [95%CI],0.56 [0.51-0.60], 0.65 [0.61-0.71], and0.88 [0.84-0.92], respectively) and in-hospital mortality (adjusted odds ratio [95%CI],0.75 [0.67-0.85],0.79 [0.72-0.88], and0.83 [0.78-0.88], respectively). CONCLUSIONS AND RELEVANCE Among patients with atrial fibrillation who had experienced an acute ischemic stroke, inadequate therapeutic anticoagulation preceding the stroke was prevalent. Therapeutic anticoagulation was associated with lower odds of moderate or severe stroke and lower odds of in-hospital mortality.

AB - IMPORTANCE Antithrombotic therapies are known to prevent stroke for patients with atrial fibrillation (AF) but are often underused in community practice. OBJECTIVES To examine the prevalence of patients with acute ischemic stroke with known history of AF who were not receiving guideline-recommended antithrombotic treatment before stroke and to determine the association of preceding antithrombotic therapy with stroke severity and in-hospital outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective observational study of 94 474 patients with acute ischemic stroke and known history of AF admitted from October 2012 through March 2015 to 1622 hospitals participating in the Get With the Guidelines-Stroke program. EXPOSURES Antithrombotic therapy before stroke. MAIN OUTCOMES AND MEASURES Stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS; range of 0-42, with a higher score indicating greater stroke severity and a score≥16 indicating moderate or severe stroke), and in-hospital mortality. RESULTS Of 94 474 patients (mean [SD] age, 79.9 [11.0] years; 57.0%women), 7176 (7.6%) were receiving therapeuticwarfarin (international normalized ratio [INR]≥2) and 8290(8.8%) were receiving non-vitamin K antagonist oral anticoagulants (NOACs) preceding the stroke. A total of 79 008patients (83.6%)were not receiving therapeutic anticoagulation; 12 751 (13.5%) had subtherapeuticwarfarin anticoagulation (INR <2) at the time of stroke, 37 674 (39.9%)were receiving antiplatelet therapy only, and 28 583 (30.3%)were not receiving any antithrombotic treatment. Among 91 155 high-risk patients (prestroke CHA2DS2-VASc score≥2), 76071 (83.5%)were not receiving therapeuticwarfarin orNOACs before stroke. The unadjusted rates of moderate or severe strokewere lower among patients receiving therapeuticwarfarin (15.8% [95%CI, 14.8%-16.7%]) andNOACs (17.5%[95%CI, 16.6%-18.4%]) than among those receiving no antithrombotic therapy (27.1%[95%CI, 26.6%-27.7%]), antiplatelet therapy only (24.8%[95%CI, 24.3%-25.3%]), or subtherapeuticwarfarin (25.8% [95%CI, 25.0%-26.6%]); unadjusted rates of in-hospital mortality alsowere lower for those receiving therapeuticwarfarin (6.4%[95%CI, 5.8%-7.0%]) and NOACs (6.3%[95%CI, 5.7%- 6.8%]) compared with those receiving no antithrombotic therapy (9.3%[95%CI, 8.9%-9.6%]), antiplatelet therapy only (8.1%[95%CI, 7.8%-8.3%]), or subtherapeuticwarfarin (8.8% [95% CI, 8.3%-9.3%]). After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeuticwarfarin,NOACs, or antiplatelet therapywas associated with lower odds of moderate or severe stroke (adjusted odds ratio [95%CI],0.56 [0.51-0.60], 0.65 [0.61-0.71], and0.88 [0.84-0.92], respectively) and in-hospital mortality (adjusted odds ratio [95%CI],0.75 [0.67-0.85],0.79 [0.72-0.88], and0.83 [0.78-0.88], respectively). CONCLUSIONS AND RELEVANCE Among patients with atrial fibrillation who had experienced an acute ischemic stroke, inadequate therapeutic anticoagulation preceding the stroke was prevalent. Therapeutic anticoagulation was associated with lower odds of moderate or severe stroke and lower odds of in-hospital mortality.

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