Temporal trends of atrial fibrillation and/or rheumatic heart disease-related ischemic stroke, and anticoagulant use in Chinese population: An 8-year study

Abstract

Background and purpose: Underuse of anticoagulants in ischemic stroke patients with atrial fibrillation (AF) and/or rheumatic heart disease (RHD) is a global concern, especially in China. However, the extent to which anticoagulants are underused in AF and/or RHD-related ischemic stroke in China has not been well characterized. We aimed to explore the temporal trends of AF and/or RHD-related ischemic stroke patients, anticoagulation use and factors related to suboptimal use of anticoagulants in a Chinese population.

Methods: Acute ischemic stroke patients admitted to department of neurology, West China hospital, Sichuan university were included from January 1st 2010 to December 31st 2017. Temporal trends of AF and RHD related ischemic strokes were compared over 2 year epochs (2010-2011, 2012-2013, 2014-2015 and 2016-2017). Multivariable logistic regression models were performed to evaluate the variables associated with non-anticoagulants at discharge.

Results: Of 4357 acute ischemic stroke patients (≤7 days after onset) included between 2010 and 2017, 823(18.9%) were AF and/or RHD-related. Over the 8 years, the proportion of RHD-ischemic stroke decreased significantly from 7.8% in 2010-2011 to 4.5% in 2016-2017, whereas no reduction in AF-ischemic stroke was observed. There was an increase in the proportion of AF and/or RHD patients who were prescribed anticoagulants at discharge (from 26.4% to 45.1%, P for trend<0.001), while the proportion given antiplatelet therapy decreased with time (from 56.0% to 30.0%, P for trend<0.001). The use of non-vitamin K antagonist oral anticoagulants (NOAC) use at discharge remained low during the study period (2.1%).Older age (per 5 years increase, OR 1.91, 95% CI 1.28-2.86), higher NIHSS score on admission(OR 1.08, 95% CI 1.05-1.11), the presence of non-symptomatic hemorrhagic transformation(OR 2.54, 95% CI 1.67-3.94) and symptomatic hemorrhagic transformation(OR 3.04, 95% CI 1.14-9.73) were independently associated with non-anticoagulant use at discharge. However, patients with a prior diagnosis of AF/RHD and anticoagulation before admission were more likely to receive anticoagulants at discharge.

Conclusions: In an ischemic stroke population in China we found an increasing but still low use of anticoagulation. Further research is required on how to improve anticoagulation use at discharge in ischemic stroke patients, including access to NOAC's.

Keywords: Anticoagulation; Atrial fibrillation; China; Ischemic stroke; Rheumatic heart disease.