The Use Of Anticoagulant And Independent Risk Factors For Recurrent Stroke In Patients With AFAIS In Shaanxi Province

There are 1.6 million patients died of cerebrovascular disease every year, and stroke has become the leading cause of death in China. Atrial fibrillation-associated ischemic stroke(AFAIS) may be responsible for at least 15% of all strokes each year, which often displays high mortality and long-term disability. Moreover, the risk for recurrent stroke in patients with AFAIS is high, ranging from10% to 20% during the first year. Mortality in patients with recurrent stroke was 2-fold higher as compared with the remaining patients. Recently, the American Heart Association(AHA) / American Stroke Association(ASA) guidelines recommended anticoagulation treatment with a vitamin K antagonist, such as warfarin, for the secondary prevention of AFAIS.Although the efficacy of warfarin has been established, it is often reportedly underused in secondary prevention of AFAIS because of requiring precise adherence and monitoring. In Canada, a prospective cohort study showed that only 39.3% were prescribed warfarin and 30% are not prescribed any oral anticoagulant therapy(OAT) on discharge. A study form America showed that 49.1% of patients with AFAIS were discharged on warfarin alone. The underuse of warfarin in China is more serious than western country. Among acute ischemic stroke(IS) patients with non-valvular AF, 19.4% were discharged on warfarin in China. The prevalence of atrial fibrillation(AF) increases markedly with age. At present, aging of Chinese population is seriously, which will lead to increase in patients with AF. Thus, our country should pay more attention to secondary prevention in patients with AFAIS.The risk for recurrent stroke in patients with AFAIS is high. A number of studies showed that the plasma level of free fatty acid, high CHA2DS2-VASc score, high NIHSS, large lesion size, advanced age and type of anticoagulant used after the index stroke seemed to be associated with recurrent stroke in patients with AFAIS. However, there is no consistent conclusion about risk factors for recurrent stroke.The purpose of this study was to investigate the use of anticoagulant and independent risk factors for recurrent stroke in patients with AFAIS in shaanxi province.Part 1 The use of anticoagulant in patients AFAIS in hospitalObjective: AF is accepted as the most common sustained cardiac arrhythmia, which is estimated to be associated with approximately 15% of all strokes. Anticoagulation therapy is recommended for the secondary prevention of stroke in patients with AFAIS. The purpose of this study was to investigate the use of anticoagulation agents in patients with AFAIS in Shaanxi Province.Methods: We reviewed medical records of consecutive patients with AFAIS who admitted to 13 hospitals of Shaanxi Province between January 2012 and May 2015 to describe the secondary prevention patterns of those patients during hospitalization.Results: A total of 1014 cases were enrolled in this study(mean age 70.3 ± 10.8 years, female 54%). According to CHA2DS2-VASc score, all patients had the indications for anticoagulant therapy. However, only 20.0% received anticoagulants(19.4% warfarin, 0.6% novel oral anticoagulants), 57.5% took antiplatelet drugs, and 22.5% received neither anticoagulant nor antiplatelet treatment. The use of anticoagulant decreased with age and CHA2DS2-VASc scores. The proportion of anticoagulant use in hospital was 28.5%, 20.7% and 13.9% in patients < 65 years, 65-74 years and ? 75 years, respectively. For patients with CHA2DS2-VASc scores of 2, 3, 4, 5, 6 and 7, the rate of anticoagulant use during hospitalization was 29.6%, 29.3%, 23.8%, 14.8%, 9.7% and 7.7%, respectively.Conclusions: In Shaanxi Province, oral anticoagulant therapy in patients with AFAIS was underused, especially in patients with higher risk of stroke. The older patients and patients with higher CHA2DS2-VASc scores have less likely to take anticoagulant agents.Part 2 The use of anticoagulant in patients AFAIS after hospital dischargeObjective: The purpose of this study was to investigate the use of anticoagulation agents in patients with AFAIS after hospital discharge.Methods: We enrolled consecutive patients with AFAIS who admitted to 11 hospitals of Shaanxi Province from January 2012 to December 2013. A one-year follow-up was made to those patients to describe the secondary prevention patterns of those patients during one-year follow-up.Results: A total of 489 cases were enrolled, 44 cases dead during hospitalization, 78 cases was lost on follow-up. Follow-up outcomes were available in 367 cases(the median age was 72 years, female 52.9%). Only 15.3% received anticoagulants(15.0% warfarin, 0.3% novel oral anticoagulants), 59.1% took antiplatelet drugs, and 25.6% received neither anticoagulant nor antiplatelet treatment during follow-up. The use of anticoagulant decreased with Rankin scores. For patients with Rankin scores of 2, 3, 4 and 5, the rate of anticoagulant use after hospital discharge was 28.2%, 17.3%, 8.5%, 4.0%, respectively.Conclusions: In Shaanxi Province, oral anticoagulant therapy in patients with AFAIS was underused after hospital discharge, which is lower than during hospitalization. The patients with higher Rankin scores have less likely to take anticoagulant agents. Part 3 Independent risk factors for recurrent stroke in patients with AFAIS during one-year follow-upObjective: The purpose of this study was to investigate the independent risk factors for recurrent ischemic stroke in patients with AFAIS during one-year follow-up.Methods: A one-year follow-up was made to patients with AFAIS who admitted to 11 hospitals of Shaanxi Province from January 2012 to December 2013. Patients were followed until death or for at least 12 months. The primary outcome in this study was a recurrent ischemic stroke. We analyzed data from those patients and examined the risk factors for recurrent ischemic stroke by univariate and multivariate logistic analyses.Results: A total of 489 patients were enrolled, 138 patients dead during one-year follow-up, 78 patients was lost on follow-up, 51(10.4%) patients experienced a ischemic stroke recurrence. Multivariate logistic analysis showed that an increased age(OR 1.648, 95% CI 1.057-2.570), history of coronary heart disease(OR 2.163, 95% CI 1.056-4.428) and stroke(OR 3.710, 95% CI 1.839-7.485), without anticoagulation agents for secondary prevention(OR 0.275, 95% CI 0.089-0.853) were independently associated with recurrent ischemic stroke.Conclusion: The present study suggested that an increased age, history of coronary heart disease and stroke, no anticoagulant treatment could be useful indicators for predicting recurrent ischemic stroke in AFAIS patients.