A 10 year study of hospitalized atrial fibrillation-related stroke in England and its association with uptake of oral anticoagulation

Q: What are the key findings of this study?

Oral anticoagulant uptake per 1% increase in AF patients with CHA2DS2-VASc ≥2 was associated with a 0.8% decrease in weekly hospitalized AF-related strokes (IRR 0.992, 95% CI 0.989-0.994, P<0.001).

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Atrial fibrillation and AF-related stroke (n=375310). Intervention: Oral anticoagulation uptake (vitamin K antagonists and direct oral anticoagulants) vs. Antiplatelet drug use or historical baseline (2009 OAC levels). Primary outcome: Weekly rate of hospitalized finished consultant episodes of AF-related stroke per 100,000 patients with AF (per 1% increase in oral anticoagulant use) (IRR 0.992, 95% CI 0.989-0.994, p=<0.001).

Q: What does this research mean for the field?

Increased uptake of oral anticoagulants in atrial fibrillation patients with CHA2DS2-VASc score ≥2 is significantly associated with a decline in hospitalized AF-related stroke rates. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To determine whether evolving patterns of oral anticoagulant use in atrial fibrillation have impacted hospitalized stroke rates in England.

J C Cowan; Jianhua Wu; Marlous Hall; Andi Orlowski; Robert West; Chris P Gale

doi:10.1093/eurheartj/ehy411

July 4, 2018European Heart JournalOpen Access

A 10 year study of hospitalized atrial fibrillation-related stroke in England and its association with uptake of oral anticoagulation

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Key result

Increased oral anticoagulant uptake linked to ~1% lower weekly AF-related stroke hospitalizations per 1% increase.

IRR 0.992
95% CI 0.989-0.994
P<0.001
n=375,310

Figures

Why the study?

Does increased nationwide uptake of oral anticoagulation reduce the rate of hospitalized AF-related stroke in patients with atrial fibrillation in England?

Key Points

To determine whether evolving patterns of oral anticoagulant use in atrial fibrillation have impacted hospitalized stroke rates in England.
Interrogated English national electronic health databases from 2006 to 2016 to assess hospital stroke admissions and oral anticoagulant prescribing.
Identified an analytical cohort of 375 310 finished consultant episodes of atrial fibrillation-related stroke drawn from 1 291 757 stroke admissions.
Modeled the relationship between weekly atrial fibrillation-related stroke rates and medication uptake in patients with a CHA2DS2-VASc score ≥2, adjusting for prevalence, age, sex, and comorbidities.
Atrial fibrillation-related stroke hospitalizations per 100 000 patients increased from 80 per week in 2006 to 98 in 2011 (difference 18.0, 95% CI 17.9–18.1) before declining to 86 per week in 2016 (difference −12.0, 95% CI −12.1 to −11.9).
Oral anticoagulant uptake among patients with CHA2DS2-VASc ≥2 rose from 48.0% to 78.6% (2011–2016 difference 25.8%, 95% CI 25.5–26.1%), while antiplatelet use declined from 42.9% to 16.1%.
After adjustment, each 1% increase in oral anticoagulant use was associated with a 0.8% reduction in the weekly rate of AF-related stroke (incidence rate ratio 0.992, 95% CI 0.989–0.994), preventing an estimated 4068 strokes (95% CI 4046–4089) in 2015/2016.

Study Design

Type

Cohort (n=375,310)

Multicenter

Yes

Structured PICO

Does increased nationwide uptake of oral anticoagulation reduce the rate of hospitalized AF-related stroke in patients with atrial fibrillation in England?

P

Population

375,310 hospitalized finished consultant episodes of AF-related stroke (mean age 81.1 years, 58.1% female) and an average of 814,501 patients with known AF annually across England, followed over 10 years from 2006 to 2016.

E

Exposure

Uptake of oral anticoagulants (vitamin K antagonists and direct oral anticoagulants [DOACs]) among patients with AF and moderate-to-high stroke risk (CHADS2 ≥2 or CHA2DS2-VASc ≥2) over a 10-year period (increasing from 48.0% in 2006 to 78.6% in 2016).

C

Comparator

Antiplatelet drug use (declining from 42.9% to 16.1%) and historical baseline oral anticoagulation uptake (e.g., 2009 levels of 49%).

O

Outcome

Weekly rate of hospitalized finished consultant episodes of AF-related stroke (ischaemic, haemorrhagic, or unspecified) standardized per 100,000 patients with AF over 10 years (1 April 2006 to 31 March 2016).hard clinical

Main Result

Relative Risk: 0.992 (95% CI 0.989–0.994)

p-value: p=<0.001

Limitations

Aggregated and unlinked data prevented tracking individual patients or adjusting for all confounding factors, creating potential for ecological fallacy
Comorbidity data were only available for hospitalized AF-related stroke cases and not for the broader AF population at risk
Primary outcome only captured hospitalized AF-related strokes, excluding community-managed strokes or pre-hospital deaths
No information on the timing of AF identified as a secondary diagnosis
Analysis was based on weekly rates of finished consultant episodes rather than unique hospital admissions
Data were aggregated at the national level and unlinked, precluding individual patient tracking and introducing potential ecological fallacy.
Co-morbidity data were only available for cases of hospitalized AF-related stroke and not for the entire AF population at risk.
Primary outcome of hospitalized AF-related stroke did not capture strokes managed in the community or patients who died prior to hospitalization.
No information was available on the timing of AF identified as a secondary diagnosis.
Analysis was based on weekly rates of finished consultant episodes rather than unique hospital admissions.

Implication

Increased nationwide uptake of oral anticoagulants (and decline in antiplatelet monotherapy) among high-risk AF patients in England from 2006 to 2016 was significantly associated with a reduction in hospitalized AF-related stroke rates, preventing an estimated 4,068 strokes in 2015/2016.

Abstract

Aims: To determine whether changing patterns of anticoagulant use in atrial fibrillation (AF) have impacted on stroke rates in England. Methods and results: English national databases, 2006-2016, were interrogated to assess stroke admissions and oral anticoagulant use. The number of patients with known AF increased linearly from 692 054 to 983 254 (prevalence 1.29% vs. 1.71%). Hospital episodes of AF-related stroke/100 000 AF patients increased from 80/week in 2006 to 98/week in 2011 and declined to 86/week in 2016 (2006-2011 difference 18.0, 95% confidence interval (CI) 17.9-18.1, 2011-2016 difference -12.0, 95% CI -12.1 to -11.9). Anticoagulant use amongst patients with CHA2DS2-VASc ≥2 increased from 48.0% to 78.6% and anti-platelet use declined from 42.9% to 16.1%; the greatest rate of change occurred in the second 5 year period (for anticoagulants 2006-2011 difference 4.8%, 95% CI 4.5-5.1%, 2011-2016 difference 25.8%, 95% CI 25.5-26.1%). After adjustment for AF prevalence, a 1% increase in anticoagulant use was associated with a 0.8% decrease in the weekly rate of AF-related stroke (incidence rate ratio 0.992, 95% CI 0.989-0.994). Had the use of anticoagulants remained at 2009 levels, 4068 (95% CI 4046-4089) more strokes would have been predicted in 2015/2016. Conclusion: Between 2006 and 2016, AF prevalence and anticoagulant use in England increased. From 2011, hospitalized AF-related stroke rates declined and were significantly associated with increased anticoagulant uptake.

Discussion

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Cite This Study

Cowan et al. (2018) conducted a cohort in Atrial fibrillation and AF-related stroke (n=375,310). Oral anticoagulation uptake (vitamin K antagonists and direct oral anticoagulants) vs. Antiplatelet drug use or historical baseline (2009 OAC levels) was evaluated on Weekly rate of hospitalized finished consultant episodes of AF-related stroke per 100,000 patients with AF (per 1% increase in oral anticoagulant use) (IRR 0.992, 95% CI 0.989-0.994, p=<0.001). Oral anticoagulant uptake per 1% increase in AF patients with CHA2DS2-VASc ≥2 was associated with a 0.8% decrease in weekly hospitalized AF-related strokes (IRR 0.992, 95% CI 0.989-0.994, P<0.001).

synapsesocial.com/papers/6a74535d8abdd9874c0a5b1d https://doi.org/10.1093/eurheartj/ehy411

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A 10 year study of hospitalized atrial fibrillation-related stroke in England and its association with uptake of oral anticoagulation

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

A 10 year study of hospitalized atrial fibrillation-related stroke in England and its association with uptake of oral anticoagulation

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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