Key result
Vitamin K antagonist cessation in the first year after atrial fibrillation diagnosis was associated with an excess stroke or TIA incidence rate of 2.29 per 100 person-years (95% CI 0.98-3.90).
Why the study?
Nonpersistence with VKA therapy in nonvalvular AF is common, but the precise risk and time course of stroke/TIA following VKA cessation during extended follow-up is unknown.
Does vitamin K antagonist cessation increase the risk of ischemic stroke or transient ischemic attack in patients with newly diagnosed atrial fibrillation?
Cohort (n=16,696)
Does vitamin K antagonist cessation increase the risk of ischemic stroke or transient ischemic attack in patients with newly diagnosed atrial fibrillation?
Effect estimate: Excess incidence rate 2.29 per 100 person-years (95% CI 0.98-3.90)
Vitamin K antagonist cessation is associated with a continuous excess risk of thromboembolic stroke or TIA, highlighting the importance of oral anticoagulant persistence, especially in the first year after AF diagnosis.
VKA cessation in AF was associated with elevated stroke/TIA risk persisting years later; leaves open optimal switching or reinitiation strategies in observational data.
Background In nonvalvular atrial fibrillation ( AF ), oral anticoagulants prevent ischemic strokes and transient ischemic attacks ( TIAs ), but nonpersistence with vitamin K antagonist ( VKA ) oral anticoagulant therapy (20–50% at 1 year) is problematic. The precise risk of stroke/ TIA after VKA cessation and its time course during extended follow‐up is unknown. Methods and Results The study cohort of incident AF in patients receiving initial VKA between 2001 and 2013 was identified from the UK Clinical Practice Research Datalink (linked hospitalizations and causes of death). Using a nested case‐control analysis, patients with incident stroke/ TIA were matched to patients without stroke/ TIA (controls). Relative risk with time since VKA cessation compared with current VKA use was approximated from conditional logistic regression. We studied 16 696 patients with incident AF and initial VKA treatment. There were 489 stroke/ TIA cases matched to 2137 controls (mean CHA 2 DS 2 ‐ VAS c score 4.3). Compared with current VKA use, the excess incidence rate of stroke/ TIA following VKA cessation in the first year after AF diagnosis was 2.29 (95% CI , 0.98–3.90) per 100 person‐years of VKA cessation or 1 additional stroke/ TIA per 43 patients per year discontinuing VKA , compared with 1.43 (95% CI , 0.97–1.88) per 100 person‐years corresponding to 1 additional stroke/ TIA per 70 patients per year, when VKA was discontinued more than 1 year after AF diagnosis. Conclusions VKA cessation is associated with a continuous excess thromboembolic stroke/ TIA risk. Increasing oral anticoagulant persistence, especially in the year after AF diagnosis, should be a therapeutic target to reduce stroke/ TIA in AF .
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Martínez et al. (2020) conducted a cohort in Incident atrial fibrillation (n=16,696). Vitamin K antagonist (VKA) cessation vs. Current VKA use was evaluated on Incident stroke or transient ischemic attack (TIA) (Excess incidence rate 2.29 per 100 person-years, 95% CI 0.98-3.90). Vitamin K antagonist cessation in the first year after atrial fibrillation diagnosis was associated with an excess stroke or TIA incidence rate of 2.29 per 100 person-years (95% CI 0.98-3.90).
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